Forensic services manual

1 Introduction

Rotherham Doncaster and South Humber NHS Trust (the trust) forensic service comprises Amber Lodge, a 13 bedded male low secure learning disability unit, which provides specialist assessment, treatment and rehabilitation for adult males detained under the Mental Health Act.

The inpatient units provide care for those who pose a significant risk to others and require physical security that impedes escape from a hospital. Individuals may have been in contact with the criminal justice system and will either have been charged with or convicted of a criminal offence, however, require treatment pathways rather than a custodial sentence.

The goal of the forensic service is to work in partnership with individuals using recovery-based approaches, enabling development to their full potential in all aspects of their lives and supporting individuals to step down to less secure placements positively and safely. All care is delivered in a safe, therapeutic environment with individualised care packages for individuals to address their learning disabilities and levels of challenging behaviours, in the context of mental health needs and offending behaviours.

The forensic service strives to work collaboratively with patients, their family, carers, Commissioning teams, provider collaborative and any other appropriate professional agencies to maintain a safe, positive environment. We work proactively towards reducing restrictive interventions around the environment, property, and person dependent on level of risk.

1.1 Security

Security provides the framework within which care and treatment can be safely provided. Neither patients nor colleagues can engage positively in the activities of the service unless they first feel safe.

Security procedures are paramount within the forensic service and all security measures employed are based upon the “see, think, act” principles which creates a pro-security culture where the responsibility for security is accepted by all. The principles of relational, procedural, and physical security are the core of the training package delivered to colleagues working in the service on an annual basis (See, Think, Act, 3rd Edition) (Royal College of Psychiatrists, 2023).

Security should have a supportive and positive role in the treatment pathways for patients, as it provides structure enabling clinical care to be delivered safely and effectively. The physical aspects of security minimise risks to all colleagues, patients, and visitors but relational aspects of security promote therapeutic relationships, improved communication and working observational practices. Relational security is by far the most important focus of the forensic service and embedded comprehensively will ensure that the whole security system, Physical, procedural and relational is able to work effectively.

1.2 Restrictive practice

Restrictive practice is making someone do something they don’t want to do or stopping someone doing something that they want to do. Restrictive interventions are deliberate acts by professionals that restrict a patient’s movement, liberty and, or freedom to act independently. Interventions like this are required in the forensic service to take immediate control of dangerous situations where there is the real possibility of harm and to prevent situations arising and also to prevent, end or reduce significant danger to patients or others (Department of Health, April 2014).

The forensic service is committed to engaging with reducing restrictive practice and will endeavour to practice to the least restrictive options available in all situations. However due to the nature of the service some procedures may be restrictive in nature to meet the needs of the patient’s group in order to ensure safe, effective and therapeutic care delivery and positive patient experience. Restrictions will be implemented in line with local and national policy and guidelines and following robust individualised assessment and collaboration with patients. All restrictions are agreed with the aim of balancing the rights of individual patients with the requirement to maintain a safe, therapeutic environment within the secure setting.

Due to the requirement for restrictive practice within the Forensic Service robust and clear guidelines on working procedures are available for all colleagues. Mandatory positive behaviour support training is delivered to all colleagues and collaborative engagement with patients to individualise care as much as possible is core to the forensic service. Patient education is essential within this to promote understanding about the required restrictions within the service to enable continued development of therapeutic relationships and safe effective treatment pathways.

2 Purpose

The purpose of the forensic service manual and the linked procedures is to provide clear, concise information and guidance on all working practices within the forensic service for all colleagues working throughout the service. The content of the manual and the linked procedures is based on sound evidenced based practice.

3 Scope

The manual applies to all forensic colleagues, whether in a direct or indirect patient care role. It is also relevant to patients, visitors, contractors and other persons who enter forensic service environments. Adherence to the procedures within this manual is the responsibility of all Forensic and trust colleagues, including agency, locum, bank colleagues and students.

4 Responsibilities, accountabilities and duties

4.1 Board of directors

The board of directors is responsible for the trust having policies and procedures in place which meet national and local requirements and, or legislation in order to provide a service which is based on best practice. The lead director responsible for this is the chief operating officer.

4.2 Directors and heads of service

All directors and heads of service are responsible for:

• monitoring compliance with the procedures within the forensic service manual
• reporting any non-compliance via the trust incident reporting system
• investigating any reported non-compliance
• the implementation of any action plans arising from the audits of the manual and patient feedback
• identifying training needs of colleagues that fall within the remit of this manual and working procedures
• ensuring that a security culture is embedded in day to day operations, with robust security risk assessments in place, evidenced based from the “see, think, act” evidence based training

4.3 Modern matron or service managers

The modern matron is responsible for making colleagues aware of and implementing this manual and for bringing any issues which may affect implementation to the attention of the head of service. Assisting as required with any subsequent investigations and action planning to ensure full compliance with the manual and working practices.

4.4 Senior sister or ward manager

Senior sisters are responsible for making colleagues aware of and implementing this manual and subsequent procedural documents and for bringing any issues which may affect implementation of this manual to the attention of the modern matron or service manager.

4.5 Ward sister or charge nurse

Ward sisters are responsible for supporting the senior sister or ward manager by making colleagues aware and implementing this manual. Ward sisters are also accountable for any auditing required with in the service and escalating concerns to the senior sister or ward manager.

4.6 Shift co-ordinator

The shift co-ordinator is responsible for day to day practice within the service environments and must escalate any non-compliance or concerns immediately to line management.

4.7 All colleagues

All colleagues must adhere to this manual and identified working procedures. Failure by any colleagues to follow the working procedures can lead to a disciplinary process, due to the severity of consequences that may arise within the service if procedures are not complied with. It is the responsibility of each individual member of colleagues to adhere to the requirements set out within this manual.

All colleagues are responsible for reporting non-compliance with this manual and working procedures to line management or the modern matron or service manager.

5 Procedures

5.1 Accessing keys from the key tracker system

5.1.1 Aim

The aim of this document is to provide service specific guidance for all colleagues who work within the forensic service who are required to use keys within and around the buildings. It is to ensure safe access to, use of, and replacement of keys through the current key tracker system. Compliance with the guidance will guarantee an efficient system is in place ensuring the security and integrity of the building and enclosed perimeters are maintained.

5.1.2 Scope

This document applies specifically to the forensic service and provides procedural guidance for use of colleagues working in this service including agency, bank and students.

5.1.3 Procedure

All colleagues identified as required to work within the forensic service will undertake a local security induction which will incorporate an individual induction on the key tracker system. On Amber Lodge, following induction each colleague will have their fingerprint image saved into the key tracker system and a specific numbered set of keys assigned to them for use. On Jubilee, following induction, colleagues will have their fingerprint image and a personal identification number (PIN) saved on the system and will select an available numbered set of keys each time they access the key tracker. Keys will not be allocated unless a security induction has been completed.

On Amber Lodge, the key tracker equipment is stored in a small room in the reception area, the door is controlled by a code lock. The code lock is not to be written down or physically input into the lock in the presence of patients. Upon entering the room ensure that the door is firmly closed to ensure your privacy when accessing the key tracker and withdrawing your keys. On exit from the room once again ensure that the door is securely closed and locked.

5.1.3.1 The procedure for routine access to the keys

1. To open the key tracker, place allocated finger onto the fingerprint reader.
2. Wait for a beep sound.
3. When the reader light goes green open the key box. If the reader shines red attempt the process again.
4. The screen will display the colleagues name and the number of their assigned keyset.
5. The assigned key set will light up blue.
6. Remove the assigned key set as it will have been released from the locking mechanism. Twist clockwise.
7. Close the key box, ensuring that no keys are catching in the door and it firmly closes.
8. Sign on the colleague signing in sheets filling in all details, key set number, pager number, security fob number and time of signing.
9. Ensure that prior to leaving the key tracker room that all keys are attached to a lanyard which is secured to their person and in a safety pouch.

5.1.3.2 The procedure for replacing keys

1. To open the key tracker, place allocated finger onto the fingerprint reader.
2. Wait for a beep sound.
3. When the reader light goes green open the key box. If the reader shines red attempt the process again.
4. The screen will display the colleagues name and the number of their assigned key set.
5. The assigned key set space will light up blue.
6. Insert the key set back in to the identified space.
7. Close the door to the key tracker securely ensuring no keys are trapped.
8. Sign out on the colleague signing in sheets with the time of departure.
9. When leaving the key tracker room ensure the door is firmly closed.

5.1.3.3 The procedure for safe keeping of keys

All colleagues are to ensure that when in possession of a key set that these are attached to an approved key lanyard that is firmly secured to their person and stored inside a safety pouch. Colleagues are personally responsible for assigned keys and should not under any circumstances swap keys or hand keys to another colleague. Key sets should not be left in any place other than the key tracker.

5.1.3.4 The procedure for unaccounted keys

1. Upon discovering a set of keys which are unaccounted for report immediately to the nurse in charge of the shift and the identified security lead.
2. Full review of all keys is to be completed immediately.
3. If the keys are not accounted for a full lock down of the unit is to be implemented and search procedures undertaken.
4. Escalate to line management within working hours and the on-call manager out of hours to inform of the situation, requirement for lock down and to seek further guidance.

5.1.3.5 The procedure for adding or removing colleagues to the key tracker

1. All members of the security team will have training to enable the adding or removing of colleagues. Training to be undertaken by lead security role.
2. Every month, security team to check access for keys and remove colleagues who no longer work at Amber Lodge.

5.2 Admission of a patient to forensic services

5.2.1 Aim

The aim of this document is to set out specific standards to follow when a patient is admitted to the forensic service. The specific standards are to be implemented in conjunction with the recognised admission checklist for all admissions to the forensic service.

5.2.2 Scope

This document applies specifically to the forensic service and provides procedural guidance for use of colleagues working in this service including agency, bank and students.

5.2.3 Procedure

5.2.3.1 Pre-admission

All referrals to the forensic service are directed to the weekly referral meeting attended by the forensic multi-disciplinary team (MDT). If the referral is considered appropriate, comprehensive access assessment is to be completed with further assessments, with input from nursing, occupational therapy, social and psychology colleagues, being completed as required if accepted for admission.

If the referral is not considered appropriate, written contact must be made with the referrer detailing the rationale for the decision and to offer guidance and support. If further details or clarification of the decision is required the referrer is to contact the responsible clinician and service manager.

5.2.3.2 Pre-admission assessment documentation

Multi-disciplinary team members undertaking admission assessments are to complete the standardised forensic pre-admission assessment documentation in full and forward to the referral meeting for discussion at the next available meeting.

Prior to the access assessment, further information is to be requested from the referring organisation:

• childhood history: developmental milestones, schooling, cause of learning disability if known, details of special educational needs such as school reports, educational reports and psychology documentation or reports
• details of early psychiatric history and any professional interventions such as child and adolescent mental health service (CAMHS) involvement
• learning disability assessments: Wechsler adult intelligence scale, adaptive behaviour assessment system amongst others
• details of the index offences: prosecution case summary, MG05, offence report, MG11, witness statement(s), MG15, record of interviews et cetera if relevant
• copies of court orders and section papers, 37/41 47/49
• medical reports from two psychiatrists if recommending section 37/41
• copy of the sexual harm prevention order (SHPO) if relevant
• print of the police national computer (PNC) record. The Ministry of Justice (MOJ) will have sent a copy of the statement from the Secretary of State for Justice to the first-tier tribunal, the Mental Health Act office will also have a copy
• annual statutory reports
• tribunal reports, medical, nursing and social circumstances
• copies of tribunal decisions
• HCR-20
• SVR-20 or RSVP if relevant
• psychology reports
• sex offender treatment programme, report, outcomes and recommendations if relevant
• physical health conditions and treatment including the health action plan
• list of medications and T2 or T3 documentation
• capacity assessments regarding medications, internet or social media, finances, contact with other
• current leave status
• all care plans
• any safeguarding concerns, historical and current
• health of nation outcome scales (HoNOS) secure
• FACE risk assessment
• any other treatment programmes completed or commenced

5.2.4 Admission declined

A copy of the access assessment report will be sent to the referrer containing advice on why the admission referral has been declined. Where clinically appropriate, clinicians will offer advice and guidance for the management and treatment of the patient as part of the access report in accordance with commissioning arrangements.

5.2.5 Admission acceptance

An access report will be compiled from all of the pre-admission assessment information. Where deemed clinically appropriate a letter will be sent to the patient detailing admission plans and treatment outlines highlighting which disciplines will be involved in the care and treatment plan.

If beds are available, admission arrangements will be made as soon as practicable possible, based on the patient’s needs and their legal status.

If no beds are available, the patient will be placed on a waiting list and updates provided to the commissioners, through the Forensic weekly referral meetings, regarding anticipated bed availability

5.2.6 Patient admission the ward

A comprehensive admission checklist (appendix A) is in place for the forensic service which is to be followed for all admissions to ensure consistent and complete admissions to the units are facilitated. In conjunction with the checklist the following actions should be completed:

5.2.6.1 Prior to admission

A responsible clinician (RC) will be identified and agree responsibility for the patient.

Where clinically indicated, other disciplines; inclusive of psychology, will be allocated.

A primary nurse team will be allocated for the patient, including a named and associate nurse, special interest worker and an associate special interest worker.

The named nurse will fulfil the lead role for the patient, co-ordinating and communicating with all relevant parties in preparation for the admission and throughout the placement. Where possible the named nurse should be on shift for the admission date however if not possible the associate nurse may be utilised.

A “buddy” patient will be identified to support the patient when they arrive to the unit and for the first 4 to 8 weeks of their admission to provide peer support.

5.2.6.2 Pre-admission day

Necessary transport arrangements must be in place. The named nurse must escalate any potential costs that may be incurred as a result of the patient’s admission to the ward manager for authorisation to be sought from the service manager or nominated deputy. Where required private ambulance secure transport can be booked, if required, through details within trust admission, transfer and discharge manual including patient flow and out of hours (OOH) procedures.

The named nurse will ensure that all relevant information is available to the full team and facilitate comprehensive handover of the patient prior to admission to the service.

5.2.7 Patient identification

Within mental health and learning disability inpatient services, it has been agreed that as patients often have periods of leave from the ward areas as part of agreed treatment pathways, they will not be routinely asked to wear identification wrist bands. In view of this the preferred method of identification is through the use of photographs uploaded into the patient’s electronic record, SystmOne. These photos are saved to the main record and also the medication chart in the system.

In the event that a patient is admitted with the same or a similar name to an existing patient an alert to this effect is to be placed on SystmOne for both patients. Patient identification can be undertaken in a number of ways, and these are clearly set out in the trust patient identification policy.

As part of the admission process the admitting nurse or nominated deputy is responsible for gaining consent from the patient for a photograph to be taken, and recording this consent accordingly in the patient’s record on SystmOne.

5.2.8 Mental Health Act requirements

Due to the nature of receiving care and treatment on a low secure and locked unit all patients admitted to the forensic service will be subject to detention under the Mental Health Act (1983). Therefore specific requirements are needed to ensure admissions to the service are authorised and lawful.

The named nurse or patient’s responsible clinician should liaise with the trust Mental Health Act office prior to admission for support with receiving and receipting of patient’s section papers.

The original section papers should be received by the nurse in charge of the shift at the time of the patient’s admission. Once legality of these papers has been confirmed the nurse in charge of the shift ensure that the detention is receipted appropriately on the correct form on behalf of the hospital managers. An attempt must then be made to explain the patient’s legal rights which should be evidenced on the form 14a within SystmOne.

In the event that the patient refuses to have their legal rights explained to them or if they lack capacity at the time of admission, arrangements must be made for further attempts to be made and recorded on the form 14a in addition to documenting in the patient electronic record.

Colleagues should refer to the trust procedure for the receipt and scrutiny of detention papers policy (Mental Health Act (1983)) and the procedure for section 132 informing detained patients of their legal rights procedure.

5.2.9 Obtaining specialist advice

There may be times when a patient is admitted who has specialist needs and in these cases, colleagues should contact the relevant trust advisor. Examples of this could be manual handling, infection control, fire safety, adult or child safeguarding issues, or police violent and sexual offender registered officer (VISOR). In cases like these colleagues should contact relevant specialist professionals within their locality to gain advice and support for the development and implementation of agreed care plans. Where possible this should be planned prior to admission however if not possible it should be undertaken at the earliest opportunity following admission to the service.

5.2.10 Handover process

The admitting professional will ensure a thorough handover is given to the receiving ward. In addition to the information detailed in section 6. The following admission details must be discussed and confirmed with the nurse in charge of the ward and recorded on SystmOne.

• Current clinical risk profile of the patient and that the admitting professional will complete or update the patients FACE risk assessment. If the admission is due to a transfer from another inpatient ward in the trust the FACE risk assessment must be reviewed and updated.
• Further information around risk, for example, risk to self, risk to others, falls, and any adult and,  or child safeguarding concerns, multi-agency public protection arrangements (MAPPA) status where known and any bail conditions or restrictions if the patient has been seen by the Liaison and Diversion team.
• Any caring responsibilities that the person being admitted to hospital may have for family, relatives including children or animals and how this is going to be managed.
• The patient’s physical health care needs and requirements, including any details of recent investigations, for example, bloods, electrocardiogram (ECG), urine analysis, and mobility needs.
• If known, original do not attempt cardiopulmonary resuscitation (DNA CPR), recommended summary plan for emergency care and treatment (RESPECT), advanced statements (original or a copy of) that the patient has in place.
• Details of current medication and any allergies.
• Contact details of family or carer to be informed of the admission and any caring responsibilities highlighted.
• Whether the patient is already known to service (this will allow the ward colleagues to gain further detail from the patient’s electronic record).
• Confirmation that the admitting professional has informed the patient that we operate smoke free sites.
• Any relevant historical information.
• Information about who has been or still needs to be informed of the admission. Where possible the admitting professional will inform the relevant people of the plan to admit as part of their assessment and immediate care duties; This may include family members; home care agencies who may be due to visit; the care-coordinator; general practitioner etc. A good handover and communication of this information enables the ward colleagues to then take over this area of responsibility as required.
• If the patient’s first language is not English and, or any specific communication needs have been identified, for example, the requirement for a British Sign Language (BSL) Interpreter, the ward colleagues should be informed of this so that arrangements can be made for an interpreter to be available at the earliest opportunity, please see interpreters policy (provision, access and use of, for patients, service users and carers).

5.2.11 Admission to hospital

What a patient should expect during their stay in hospital
During their stay in hospital patients should expect to have their privacy, dignity and confidentiality respected and to be treated in a holistic person-centred manner.

Interventions should be purposeful and carried out with the patients consent where possible or under an appropriate legal framework.

Colleagues will start to build therapeutic relationships as early as possible to:

• ensure the person feels supported and is an active participant in their care
• encourage the person to engage with treatment and recovery programmes
• collaborative decision-making
• create a safe, contained environment
• reduce the risk of suicide, which is increased during the first 7 days after admission

Communication between the multi-disciplinary team should take place in a timely way to ensure care is streamlined and in most cases, recovery focussed, with the aim being towards successful discharge.

5.2.12 Orientation and information

On admission to the ward, patients will be welcomed by colleagues and shown around the ward being introduced to the various colleagues and other patients. The patient will be offered refreshments and addressed using the name and title they prefer.

Patients and carers will be asked to wait where they most feel comfortable before the admission clerking process begins (subject to risk assessment and staffing levels).

Patients will be provided with the name of the doctor under whom they have been admitted and when they are likely to see the person who will be managing their care.

At the earliest opportunity, the admitting team should provide the patient and their family, carer, or advocate with an opportunity to discuss their care. Discussions should be documented on SystmOne and cover:

• place of care and reason for admission to hospital
• daily routines (including the use of medicines and equipment)
• mealtimes and menu choices and meaningful activities available including timetables
• any visiting times or arrangements
• any restrictions they may be subject to whilst on the ward including the Mental Health Units (use of force) Act (2018)
• any known risks including safeguarding and any additional support required
• an explanation of confidentiality, its limits, and patient preferences for sharing information with third parties
• advance statements or advance decisions to refuse treatment (ADRT) in place
• what contingency plans may be required
• end-of-life care wishes where relevant
• any lasting powers of attorney for health and welfare or deputyship

On admission patients will be offered access to independent advocacy services that will take into account their language, communication, cultural, social needs and protected characteristics.

Consideration should also be given to identify whether there is a need for reasonable adjustments to be made to accommodate the patient in hospital. This is in line with the Equalities Act (2010). Examples include:

• providing communication aids (this might include an interpreter)
• ensuring there is enough space around the bed for wheelchair users to move from their bed to their chair
• single sex accommodation
• support for cognitive difficulties

Patients will be supported with their cultural and spiritual needs including meals, access to faith book or materials, a faith room and support from the trust chaplaincy where appropriate.

Patients should be given accessible written information which colleagues talk through with them as soon as is practically possible.

The information includes:

• their rights regarding admission and consent to treatment
• rights under the Mental Health Act including right to appeal
• how to access independent advocacy services
• how to access a second opinion
• interpreting services
• how to view their records
• how to raise concerns, complaints and give compliments
• the identified contact or link person for each agency involved with their care
• patients will know who the key people are in their team and how to contact them if they have any questions, patients will also be informed of the colleagues who is their first point of contact for each shift

5.2.13 Other considerations

On admission the following is given consideration:

• the security of the patient’s home
• arrangements for dependants (children, people they are caring for)
• arrangements for pets
• benefits
• essential maintenance of home and garden

5.2.14 Action on patient’s arrival in the ward or as soon as practicable

Please refer to appendix D, the nursing admission checklist which details all actions to be completed on and within 72 hours of admission to hospital.

The admitting nurse will contact the ward doctor if admission takes place between Monday to Friday 9am to 5pm, otherwise contact the on-call doctor to notify them of the patient’s arrival on the ward and agree who will be completing which sections of the admission assessment. It is the responsibility of the ward doctor or on-call doctor to clerk the patient in and undertake the physical health and wellbeing assessment. Please see physical health policy.

Initial admission tasks to be completed by ward colleagues using the Inpatient launchpad on SystmOne. In the event that any of these cannot be fully completed a note is to be made as to the reason why and arrangements made for their completion the next day in line with local arrangements, for example, handover documentation, diarise, and no later than 72 hours following admission.

5.2.15 Admission care plan

All patients will have a 72-hour admission care plan to meet their immediate needs and risks, taking into account the patient’s orientation to the ward and detailing their observation status. All colleagues involved in the patient’s admission need to be mindful of the fact that admission to hospital can lead to an increase in the level of stress or distress being experienced by the patient and that the provision of timely information and support can help to alleviate this. However, colleagues should take a thoughtful and sensitive approach to the patient’s presenting needs and whilst some aspects of the admission are to be completed immediately others may be completed as soon as is clinically appropriate.

5.2.16 Restrictions

Ward colleagues and the multi-disciplinary team (MDT) will ensure that any restrictions on access to personal possessions are necessary and proportionate in relation to the person concerned and are in line with the trust blanket restrictions policy and the prohibited and restricted items management procedure.

5.2.17 Care planning when a patient declines or lacks capacity to be involved

There may be times during a patient’s episode of care and particularly at point of admission when the patient may either decline or lack the capacity to be involved in the planning of their care. In these circumstances colleagues are to clearly document in the patient’s electronic record why the patient has not been involved in the development of their care plan.

Patient’s engagement and capacity can change at any point during an episode of care therefore it is important that colleagues make ongoing attempts to involve the patient, recording all attempts comprehensively. Where required the use of Mental Capacity Act will be considered in line with Mental Capacity Act (2005) policy.

Some patients may have advance decisions or statements following previous involvement with mental health and learning disability services which must be considered during any care planning pathways.

Colleagues should refer to the trust policy for advance statements and advance decisions to refuse treatment policy for full details and guidance.

5.3 Control of the airlock

5.3.1 Aim

The aim of this document is to provide service specific guidance for colleagues who work in the forensic service to ensure safe access and egress to Amber Lodge low secure unit.

5.3.2 Scope

This procedure applies to the control of the airlock for all colleagues, patients and visitors to Amber Lodge low secure unit, and forms part of the low secure care standards requirements utilised by the forensic service.

5.3.3 Procedure

Secure services should have a single main entrance to and exit from the building with an airlock operated by reception to co-ordinate the entry and exit of all colleagues, patients and visitors. There is a difference when out of hours and access is via fingerprint for approved colleagues (see separate document). Although essential for security purposes the entrance should be welcoming, appropriate to the healthcare setting and should operate efficiently.

Clear guidance should be available for all colleagues to ensure that the operation of the airlock is managed consistently; this can be found in this procedural document, control of the airlock.

5.3.3.1 The airlock

The airlock comprises the front entrance area to both Amber lodge. There are two sets of doors external and internal, both controlled by a magnetic device and locks. Each set of doors operates separately and independently of the other set, however both sets of doors are interlocked such that one set of doors has to be closed before the other will open, for example, the internal doors cannot be opened until the external doors have been closed and vice versa. The airlock is the area between the two doors.

In the airlock should be situated:

• the reception area with a window which separates the admin reception office from the airlock space
• visitor’s lockers for storing restricted or prohibited items, bags and other valuables
• fire panel
• personal alarm cabinet (keypad lock operated). Only to be accessed when patients have moved from the airlock
• on display should be a copy of the restricted and prohibited items for the service
• CCTV cameras are in operation outside the external doors and in the airlock area, monitors for these cameras are located in the admin and nursing offices to allow for observation of the airlock area
• feedback forms

5.3.3.2 Important information

A maximum of 4 people should be in the airlock at any one time.

Under no circumstances should the airlock be utilised as a fire evacuation point.

5.3.3.3 Entering the airlock from outside the building

To the right of the door is an electronic fingerprint reader which colleagues will be able to use to open the external door to enter the airlock area (Amber Lodge only).

To the right of the door is an intercom system and buzzer which can be pressed to alert reception or the nursing office, out of normal working hours, to gain attention and access to the airlock area. Colleagues may communicate directly through the intercom system prior to releasing the door locking mechanism to allow entrance.

Reception colleagues or nursing colleagues, out of normal working hours, will attend the airlock directly to greet visitors and colleagues external to the forensic service.

5.3.3.4 Management of a faulty airlock

Upon discovering the doors in the airlock are faulty, notify your team members as soon as possible, however, do not leave the area unattended as it is now a security risk.

Escalate to line management within working hours and the on-call manager out of hours to inform of the situation.

This situation should be escalated to Micro Alarms at the earliest opportunity.

The nurse in charge is to set a rota for colleagues to keep the doors attended at all times and must report the problem immediately.  Doors can be locked using the override key; however colleagues must remain there at all times for access and egress to the unit.

Ensure all documentation is completed and an IR1 completed for reporting purposes.

5.4 Discharge transfer from forensic services

5.4.1 Aim

The aim of this document is to provide additional guidance to the trust’s policy for discharge and transfer of patients when preparing for and completing discharge and transfer of patients from the forensic service. The document offers guidance based on best practice and should be used for all transfers and discharges from Amber lodge.

5.4.2 Scope

This document applies specifically to the forensic service and provides procedural guidance for use of colleagues working in this service including agency, bank and students during the process of transfer and discharge of patients.

5.4.3 Procedure

A transfer from the forensic service would result in the patient moving to another hospital of either a lesser or greater level of security.

Discharge from the forensic service involves the patient being discharged from Amber Lodge into a community service placement.

5.4.4 Responsibilities of the multi-disciplinary team

5.4.4.1 9 to 12 months prior to planned transfer or discharge

• Revisit treatment outcomes and milestones to give confidence that treatment will be completed in 9 to 12 months. Consider who can or should advocate for the patient at this time, for example independent mental capacity advocate (IMCA), family member, general advocate.
• Develop and agree an integrated, person-centred plan for discharge, considering the views and wishes of the patient and their advocates and carers (if applicable).
• Allocate a social worker or care manager to undertake the patient’s needs assessment.
• Assess the patient’s capacity to make decisions in specific areas if indicated, for example, regarding future residence, care and treatment, contact with others, finances, tenancy, shopping, internet access, social media, phone access.
• Develop a person specification identifying the type of accommodation, care requirements, colleagues’ requirements (for example, how many, training, skills and experience required), number of people in the accommodation (including no others) and location of accommodation.
• Undertake risk assessments capturing the risks posed to and by the patient in a potential discharge environment.
• Develop a positive behavioural support (PBS) plan for discharge.
• Make necessary referrals for discharge, for example, community responsible clinician, social supervisor, community support, occupational therapy (OT).
• Arrange a care and treatment review (CTR) to be held within recommended timescales and multi-disciplinary team processes to review progress.
• Identify funding stream (section 117, joint funding) and responsible funding authority.

5.4.4.2 6 to 9 months prior to planned transfer or discharge

• Ensure the responsible funding authority has agreed the funding in principle based on the pen picture and service specification to allow the procurement process to commence.
• Develop detailed practical transition plan and identify all steps required for successful discharge. Ensure the transition plan includes contingency, crisis and risk management plan.
• Prepare a personalised easy-read booklet, outlining the steps required for successful discharge, for the patient’s own use and support them to access it.
• Make best interests decision where required in relation to tenancy. LA to ensure Court of Protection (CoP) process underway once home address is identified, if this is needed.
• Ensure appropriate is property found, tenancy agreed, adaptations identified and works planned with agreed timescales. Confirm placement or provision and ensure the contract is awarded.
• Arrange additional professionals or multi-disciplinary team meetings to foresee potential barriers.
• Hold care and treatment review (CTR) to assure planning if concerns that discharge delay is a risk.

5.4.4.3 3 to 6 months prior to planned transfer or discharge

• Confirm funding for the individual person-centred support plan from the responsible funding authority and confirm its route of delivery, for example, personal health budget (PHB), direct payment or commissioned service.
• Where applicable, notify the finance appointee of the intention of transfer or discharge and the planned date.
• Include the patient and their family, where appropriate, for co-production.
• Make best interests decision where required for accommodation, care and treatment, plus any restrictions. Make Court of Protection application, if required.
• Finalise care colleagues recruitment and training where required (for example, by forensic outreach liaison service (FOLS), in line with the person centred plan and PBS plan.
• Hold multi-disciplinary team review and care and treatment review to agree that treatment goals are achieved and confirm transition plan.
• Where the placement is subject to section 37 or 41 of Mental Health Act (MHA), determine when the tribunal hearing should be applied for.

5.4.4.4 Less than 3 months prior to planned transfer or discharge

• Ensure necessary legal frameworks in place to facilitate transfer or discharge.
• Ensure transition plan in place and being actively followed. Colleagues from the intended placement should attend Amber Lodge to meet, understand the needs of, and develop a therapeutic relationship with the patient prior to the patient using section 17 leave to attend the placement.
• Ensure risk management, crisis or contingency plans are agreed and well understood by all, including the patient and their family, and that all of the resources for those plans are in place.
• Ensure that a best interest decision or consent has been given for inclusion on dynamic risk register at the point of discharge.
• Ensure Welfare Benefits have been applied for, where appropriate.
• Liaise with the receiving responsible clinician, Mental Health Act office, and the Ministry of Justice (MoJ) to arrange the transfer.
• Ensure that all relevant paperwork is in place prior to transfer or discharge, such as Ministry of Justice authorisation and section 17 leave, if applicable.
• Confirm details of the general practitioner (GP) doctor service in the receiving area and identify an allocated GP for the patient.
• For transfers, ensure a professionals meeting is arranged and held with the receiving responsible clinician (RC) in attendance alongside the service, care coordinators and patient’s family or carers.
• For discharges, ensure that a section 117 aftercare meeting has been held with the community responsible clinician, support services involved in the care, and the patient’s family or carers in attendance.

5.4.4.5 Immediately prior to and on the day of discharge

• Ensure that transport required is agreed and arranged, plus escorting colleagues are identified, at least 7 days prior to transfer or discharge.
• Ensure that to take out (TTO) medication is ordered at least 5 days prior to the agreed date of transfer or discharge. To take out medication must be available and sent with the patient along with a copy of the patient’s prescriptions.
• Ensure that all Mental Health Act paperwork is readily available and transferred with the patient. These must be original documents. Liaison with the trust Mental Health Act office is essential to prepare this documentation and to notify them of decisions to transfer or discharge the patient.
• Ensure that appropriate professionals are involved in the transfer, so effective handover can be provided to the receiving service. This must include recommended summary plan for emergency care and treatment (ReSPECT) forms (if applicable) and do not attempt cardiopulmonary resuscitation (DNACPR) status.
• Ensure that all patient belongings and personal items inventory are transferred with the patient.
• Ensure that all valuables (if applicable) which are stored in the trust valuables safe are retrieved in a timely manner for the date of transfer, so that they can go with the patient.
• Ensure that support is provided (if applicable) with packing patient belongings and personal items prior to the moving day.
• Ensure that where appropriate, the Ministry of Justice are informed of the confirmed transfer of the patient.

5.4.4.6 Immediately following transfer or discharge

• Once the patient has left Amber lodge, it is to be documented on the patient electronic record (SystmOne) and the patient is to be removed from the bed states and fire board.
• A confirmation email is to be sent to the Mental Health Act office, responsible clinician, finance department and any other relevant professionals involved, such as care coordinator and police public protection unit (PPU) officer, where appropriate.
• The patient room is to be cleaned in line with the infection, prevention and control manual.
• If consent was given by the patient, a phone call is to be made to their family or carers to confirm transfer of the patient.
• Ensure follow up by the social worker or care manager in the new placement, within one week of transfer or discharge.
• Hold a care programme approach (CPA) meeting within four weeks of transfer or discharge.
• Ensure that contingency arrangements are still in place if required after four weeks. Forensic outreach liaison service (FOLS) practitioners to continue to visit.
• Ensure that a review mechanism via multi-disciplinary team and care and treatment review is in place for the medium term.

5.4.5 Transition planning

As stated in the section above, a personalised transition plan must be developed for each patient and provided to them in an individualised format.

5.4.5.1 Transition plan easy-read booklet

Each patient transition plan booklet must include:

• an explanation of the technical terms and acronyms appropriate to that patients discharge or transfer for example, Ministry of Justice, Integrated Care Board (ICB), Deprivation of Liberty Safeguarding (DoLS), conditional discharge, capacity assessment
• the steps patients must take to engage with their treatment to demonstrate that it is appropriate to progress with the transition plan for example, taking medications, attending occupational therapy (OT) sessions, utilising Section 17 leave appropriately, attending psychology sessions, attending multi-disciplinary team meetings
• an explanation of the steps required to identify a suitable placement as outlined in the section, 9 to 12 months prior to planned transfer or discharge
• the key individuals involved in the transition plan for example, placement colleagues, social supervisor, social worker, care co-ordinator, probation officer, responsible clinician, GP, forensic outreach liaison service (FOLS) practitioner
• an explanation of the incremental increase in day visits, and later night visits, to the new placement, and the required applications
• an outline of the potential conditions that may be included in a conditional discharge or release on licence for example, restrictions on address, medications, appointments, jobs, relationships, travel, alcohol, illicit substances, internet access, leave

5.4.6 Unplanned or emergency transfer

Any unplanned or emergency transferred required will be led by the provider collaborative in conjunction with the ward and led by the responsible clinician.

5.5 Escorting patients, Amber Lodge or forensic services

5.5.1 Aim

The forensic service recognise that escorted leave is an important part of a patient’s recovery and enables clinical decisions to be made regarding a patient’s progress through their care pathway. Therefore, the aim of this document is to provide guidance for all colleagues, to ensure that the service is fully compliant with the standards of escorting, as detailed in the Standards for Low Secure Service, Royal College of Psychiatrists (2023). Providing a consistent approach and practice standards will ensure that managing of risks when escorting patients detained under the Mental Health Act (MHA) will be safe for patients, colleagues and the general public.

5.5.2 Scope

This document applies specifically to the forensic service and provides procedural guidance for use of colleagues working in this service including agency, bank and students. It applies to all colleagues who may be required to escort patients detained under the MHA for the purposes of recreation, home visits, leisure, hospital appointments, hospital transfers, court appearances or other possible reasons for leave.

5.5.3 Procedure

Each patient’s individual escorted outing will differ and requirements for the outings to be escorted safely will be risk assessed and robust risk management plans implemented as required.

The trust and forensic service have specific duties under section 11 of the Children Act (2004) to make arrangements to safeguard and promote the welfare of children and is committed to these responsibilities.

The Mental Health Act (1983) and its Code of Practice (Department of Health, 1999, draft revision 2007) set out the requirement for local policies to safeguard children’s rights in relation to private and family life and to promote good practice.

The decision to allow or deny the presence of children during a planned visit will be based on risk assessment. Where risk assessment identifies concerns, detailed planning will be required, involving all possible agencies. In accordance with the Children Acts (1989 and 2004) the welfare of the child is paramount and takes primacy over the interests of any and all adults.

5.5.3.1 Risk assessment

In line with standards 24 and 25 of College Centre for Quality Improvement (CCQI), the team and patient jointly develop a leave plan, which is shared with the patient, that includes:

• the aim and therapeutic purpose of section 17 leave that clearly links to the overarching plan for the care pathway
• a risk assessment and risk management plan that includes an explanation of what to do if problems arise on leave
• conditions of the leave
• contact details of the ward or unit and crisis numbers
• colleagues agree leave plans with carers where appropriate, allowing carers sufficient time to prepare

It is important that the patient is included in all discussions regarding leave and engaged with the escorted leave care planning agreeing with decisions. Patients are to be given opportunity to express their views and participate in the formulation of their care plans, to agree to comply with the conditions and stipulations that have to be applied.

All patients will have formal risk assessments completed on admission which will include identification of their risk of absconding and any other relevant factors whilst on escorted leave. The risk assessment will identify whether the patient falls into a low, medium or high-risk category.

The risk assessment must be documented in their individualised care plan, where appropriate detailing gender and number of colleagues required for the escort.

The risk assessment and care plan will be subject to regular review and updated as appropriate at each multi-disciplinary team (MDT) meeting and also when clinical need is identified.

Medium and high-risk patients must on admission have escorted leave care plans in place to ensure unplanned leave such as medical emergencies, court attendance and hospital appointments are managed safely.

Before any escorted leave can be undertaken the responsible clinician (RC) will complete a section 17 leave form reflecting risk assessment requirements and Ministry of Justice restrictions and stipulations if in place.

Restrictions on escorted leave such as times of leave, means of transport and communication requirements will be reviewed by the multi-disciplinary team (MDT) and will only be in place where clinically indicated for safety.

All patients will receive verbal and written confirmation of any restrictions that will need to be imposed on them as part of the section 17 leave and will be included in the leave care plan.

Identified restrictions, such as random pat down searches or random drug and alcohol testing for example will be included in the patient care plan.

Any restrictions in place must be shared with escorting colleagues prior to section 17 leave being undertaken.

5.5.3.2 Low risk

• Patients assessed as being low risk will have no recent history of absconding or of threats to abscond and will be assessed as presenting with no immediate danger to themselves or others if they do abscond.
• They will not be detained by the courts on remand and will currently have a stable mental state.
• They may also have unescorted leave authorised.
• They will be able to undertake escorted leave as a group activity with a ratio of a minimum of one-to-two, one colleague to 2 patients, as well as one-to-one leave, one colleague to one patient.
• A driver may be the escorting colleague for low-risk patients.
• Colleagues undertaking one-to-one escorting leave duties must be conversant with the trust’s lone working policy and have completed all relevant lone working risk assessment. Use of trust mobile phones are also to be used when lone working.

5.5.3.3 Medium risk

• Patient identified as medium risk will have been assessed as having a history of absconding with threats to abscond or may be assessed as having some impulsive behaviour that poses a risk to themselves or to others if they do abscond.
• Their mental state may currently be in a state of flux.
• They will have no unescorted leave authorised.
• Only one-to-one, one colleague to one patient, escorted leave will be authorised.
• Group escorted leave can only be taken if the patient has an identified colleague to fulfil the one-to-one requirement whilst on the group leave.
• A driver cannot be included in the escorting colleague.

5.5.3.4 High risk

• Patient identified as high risk will have been assessed as having a history, recent and historical, and threats to abscond.
• They may pose an immediate risk to themselves or to others if they should abscond.
• They may exhibit a marked deterioration in mental state.
• They may have no authorised leave.
• May be detained or restricted by the courts.
• There may be significant political, or media interest attracted.
• Leave for leisure purposes will not be authorised, leave will only be for essential purposes, such as:
  • transfer to another hospital
  • attendance at court
  • attendance at a police station
  • hospital appointments
• All leave must be agreed and authorised by the full multi-disciplinary team, consideration to be given if secure transport would be required (see Safe transportation of patients and staff (adult and older person’s mental health and learning disability)).
• A minimum of 3 colleagues trained in reducing restrictive interventions (RRI) techniques will be required to undertake the leave. The lead escort must be a registered nurse.
• Drivers will not be included in the number of the escorting colleague.
• Police manager involvement may be appropriate with additional supportive measures such as CCTV coverage whilst on leave.

5.5.4 Assessments and standards for escorted leave

There are minimum standards which apply to all three categories of risk, with additional requirements for the medium and high categories.

All escorting colleagues are expected to adhere to the minimum standards for all categories of leave.

All patients undertaking leave must have an escort status risk assessment (appendix E).

If the patient is visiting their family in a home environment a home risk assessment (appendix F) must be completed in addition to the section 17 leave risk assessment. The home risk assessment must be discussed and agreed in the multi-disciplinary team prior to leave being authorised.

5.5.4.1 Standards for escorted leave

• To ensure that a pre-brief is completed with the patient prior to every leave and to ensure that this is documented on SystmOne.
• Be aware of all items of patient property taken on leave, for example, money, clothing, food. Ensure that the amount taken is agreed on a person-centred basis around individual risks.
• To be fully briefed about the patients undertaking the leave and the conditions and stipulations that have been applied to the leave.
• To adhere to the plan of leave and section 17 documentation.
• To know of the patient’s individual care plans and any specific instructions to be followed throughout the leave, such as use of toilet areas and what needs to be supervised.
• To encourage the patient to take full advantage of any escorted leave and engage with planned activities.
• To intervene if the patient displays any undesirable behaviours as highlighted in risk assessments and care plans.
• Keep the patient safe at all times.
• Try to prevent the patient from absconding, utilising pre-briefing and care planning guidance, using reasonable means.
• To be conversant with the procedures to be undertaken in any eventuality or emergency.
• To make every effort to return safely to the ward.
• To be able to observe the patient and engage appropriately with them at all times and remain in close proximity during the leave period.
• To undertake a debrief following the leave with the patient and the nurse in charge or shift co-ordinator, and to record details of the leave as appropriate, and ensure that this is documented on the electronic patient record SystmOne.

5.5.5 Roles of colleagues for escorted leave

5.5.5.1 Nurse in charge or shift co-ordinator

Will determine the colleagues to escort the patient, taking into account the number of escorts required, identified factors required such as gender of colleagues and skill mix, as identified by the multi-disciplinary team.

If more than one patient is being escorted staffing will be assigned as per individual patient leave status and associated qualifying factors highlighted in risk assessments and care plans.

Escorts will be allocated to be responsible for named patients prior to leaving the ward, and the lead escort will have overall responsibility for the group.

On occasion there may be specific clinical reasons for the patient’s leave to be reconsidered such as concerns about their mental state or increased risk of absconding.

If the decision is made to postpone or cancel leave the patient must be informed and a full explanation offered. Any decision must be recorded in the patient’s electronic notes, SystmOne.

Notification of the leave cancellation must be given to the responsible clinician and senior nursing colleagues as soon as practicable.

Discussion of the cancelled leave will be held at the next multi-disciplinary team meeting.

Any identified escorts will have a full briefing from the nurse in charge or shift co-ordinator regarding the patient’s individual specific requirements, conditions and stipulation for their leave as highlighted by the multi-disciplinary team, risk assessments and care plans.

The nurse in charge or shift co-ordinator also holds the responsibility for briefing the patient of any such conditions prior to undertaking the escorted leave.

Particular attention should be given to briefing escorts on any action to be taken, by means of prevention of absconding, or if the patient should abscond.

Any relevant information concerning emotional, physical or social factors for the patient should be given to the escorting colleagues to ensure that the care and wellbeing of the patient whilst on leave is effective and therapeutic.

Full debrief upon return from leave for the escorts is to be undertaken, and all documentation completed as required.

The patient should also complete a full debrief of leave with the escorting colleague and details of this recorded in the care plan and also the multi-disciplinary team notes.

Any leave facilitated for faith purposes, colleagues should seek support and advice and work with faith leaders through the trust chaplaincy department.

5.5.5.2 Lead escorts

Where more than one colleague is designated to escorting a patient, or a group outing is taking place, it is important that one colleague is designated lead escort by the nurse in charge or shift co-ordinator.

The lead escort is to ensure they have a full briefing about the patients undertaking the leave and are fully aware of all conditions that must be applied. The briefing is not limited to, but issues covered should include, the following:

• the purpose of escorted leave
• details of transport and expected time of return
• the conditions, stipulations of the leave, to cover issues such as location, behaviour boundaries, meeting specified individuals, intake of alcohol
• familiarity with the patient and their individual needs and care plans
• medications required during leave, including PRN medication for physical health issues
• if a detained patient fails to return to the ward at the agreed time they are classed as absent without leave (AWOL) and must be returned under section 18 of the Mental Health Act (1983) employees should refer to the trust wide patients missing or absent without leave (AWOL) policy for detailed guidance, arrange the method of communication with the ward whilst undertaking the leave
• ward mobile phones are to be signed out for leave purposes to ensure communication is facilitated to notify of return timings or to alert the nurse in charge or shift co-ordinator of any problems with the leave
• any information or documentation required for the leave is to be taken as necessary, for example, medical notes, prescription card and appointment cards for hospital appointments.
• a full discussion with the patient to ensure clarity on conditions and stipulations of leave will be held prior to leaving the ward.
• documentation of the leave and any outcomes must be recorded in SystmOne appropriately and a handover provided to the nurse in charge or shift co-ordinator and documented in the care plan and multi-disciplinary team update notes.

5.5.5.3 Escorts

When patients are on an individual one-to-one escorted leave, the escorting colleague will be the lead escorts as detailed in section 6.2 and must ensure they are compliant with the briefing as detailed in this section.

Escorts must be in possession of a trust staff identity card and carry this at all times as proof of authority to act as an escort to the patient. In the trust grounds this can be worn visibly however for community escorting it must not be on show.

Colleague belts and key pouches must not be worn for any escorting leave.

The use of wearing trust uniform will be agreed and shared within the patients individualised care plan.

The overall organisation and planning of escorted leave is mainly within the role and function of the lead escort and the nurse in charge or shift co-ordinator.

All escorted colleagues must be clear on their role and responsibilities and maintain the required practice standards in this procedure.

5.5.5.4 The patient

It can be assumed that, because leave is to be escorted, the patient has not yet reached the point in their treatment to be granted full unescorted leave and that legal constraints eliminate unsupervised leave as an option.

All section 17 leave documentation must have the leave care plan attached and be given to the patient and identified carer as or if appropriate.

Accompanied care and leave maybe considered as an option for patients. This would be discussed and agreed within the multi-disciplinary team meeting and if appropriate agreed section 17 leave care plan devised between carer, patients and multi-disciplinary team, which would include all necessary guidance and support.

Arrangements are to be made for a contact number to be given for them to seek advice and guidance if needed.

The patient can expect to receive a briefing by the colleagues escorting the leave prior to and following the escorted leave activity.

Patients are to be encouraged to express their views, relate their experiences and make comments through the briefing period’s pre-leave and post-leave.

5.5.6 Preparation for high-risk leave

The lead escort, registered staff nurse, is/are responsible for making the appropriate transport bookings and confirming arrangements.

The driver must not be counted in the escort team.

The escorting colleagues must be adept at implementing reducing restrictive intervention (RRI) techniques and be up-to-date with training requirements.

The lead escort must check that all the requirements and arrangements specified in the care plan are confirmed, for example appointment times.

The lead escort must obtain a copy of any care plan introduced for the high risk leave and take this on the escorted leave and ensure it is fully adhered to.

The lead escort must maintain communication with the ward through the ward mobile phones utilised for escorted leave.

The lead escort will brief all escorts and the driver before commencing the high risk escorted leave with the patient.

Only when all members of the Escort team are satisfied that they are conversant with all the conditions and requirements of the escorted leave (as detailed in the fully completed section 17 leave and care plan documentation) will the high risk escorted leave be considered or recorded as undertaken.

5.5.7 Contingency plan

In the Mental Health Act Code of Practice (1983) colleagues who are escorting patients detained in accordance with the Mental Health Act are expected to prevent the absconding of a patient under their care using every reasonable means at their disposal.

A detained patient on any escorted leave who absconds from their escorting colleagues or refuses to return to ward when required to do so can be deemed to have absconded. In this case it is lawful for the escorting colleagues, as the person who had the patient’s custody immediately before absconding, to retake them, but only if colleagues feel it was safe to do so.

Prior to escorted leave, especially high risk, all escorts will be briefed by the nurse in charge or shift co-ordinator as to what action they should take, if the patient absconds.

The trust wide patients missing or absent without leave (AWOL) policy should be adhered to for section 17 leave. Section 6 authorises restraint provided that the officer or colleague reasonably believes that it is necessary to do the act in order to prevent harm to the patient. And that restraint is a proportionate response to:

• the likelihood of patient’s suffering harm
• the seriousness of that harm

5.5.7.1 Contingency plans can include the following

In the event of an absent without leave please follow the trust wide patients missing or absent without leave (AWOL) policy seeking support from the ward via phone alongside informing the police.

There must not be changes to the content of the planned escorted leave unless an emergency situation arises, which should be reported to the nurse in charge or shift co-ordinator as soon as possible, advice should be given regarding any required changes to the leave.

It is not recommended that a single escort follows a patient who absconds in order to keep them in view. A minimum of 2 colleagues should follow the patient, with one being in contact with the patient’s ward and, or the police to update on the patient’s location. Colleagues must ensure that their safety will not be compromised to follow the patient.

Colleagues need to understand that they must not put their safety at risk or that of others in taking measures in order to prevent a patient from absconding.

Escorting colleagues who have any concerns about their ability to return the patient safely should request assistance from the police.

Any incidences of absconding will be reported at the earliest opportunity to the responsible clinician and all relevant documentation will be completed, including a completion of an IR1 form.

In the event that the patient does not return to the ward by midnight on the first day of absence complete and email the Care Quality Commission absent without leave notification form to the Care Quality Commission. Then send the original to the service manager or matron or Mental Health Act office.

Notify the Mental Health Act office of the absent without leave.

Complete the required, this is needed for any absent without leave incident going past midnight (do not complete on-line print and send to the relevant areas, scan and save to SystmOne).

5.6 Fingerprint access system (FAS) at Amber Lodge

5.6.1 Aim

The aim of this document is to ensure that the fingerprint access system (FAS) currently in operation on Amber Lodge, low secure unit, is managed effectively and robustly monitored. This system facilitates secure access to, movement within and exit from Amber Lodge so it is essential that it is fully functioning.

5.6.2 Scope

This document applies specifically to the forensic service and provides procedural guidance for use of colleagues working in this service including agency, bank and students.

5.6.3 Procedure

5.6.3.1 Assessment and inclusion criteria for all colleagues

All colleagues, both new and existing, will be individually assessed in relation to their requirements to access Amber Lodge using the fingerprint access system against the following criteria:

• is the individual employed by the forensic service or the trust, for example domestic, pharmacy or estates?
• does the individual require regular access to Amber Lodge?
• is there a clear rationale why the individual needs regular access to Amber Lodge?
• has the individual attended security awareness training (SAT)?

5.6.3.2 Approved access to the fingerprint access system

If the colleague meets the above criteria complete form A (appendix B) and send to the ward manager for approval. Documentation must be collated for all colleagues and authorised to have access to the system.

5.6.3.3 Gaining access to the fingerprint access system

On receipt of form A one of the designated security team leads will complete the procedure of inputting the colleagues’ fingerprints onto the fingerprint access system (FAS). Once the fingerprint is stored this will enable the colleagues to access and egress from Amber Lodge.

On completion of this process a copy of form A will be placed on the colleagues personal file and their name added to the approved colleague list, form C (appendix D).

5.6.3.4 Removal from the fingerprint access system

Colleagues can be removed from the FAS for a number, or reasons, for example, leaving employment with the forensic service; no longer requiring regular access to Amber Lodge or suspension from service. This is not an exhaustive list and decisions for removal will be individualised.

Following a decision to remove a colleague from the list, the ward manager will instruct a member of the nominated security team leads to complete the removal process from the computer system. The security lead will complete form B (appendix C) and update form C. In addition to this the original form A must be scored through and signed for and returned to the ward manager for the colleagues personal file. FAS access will be reviewed monthly by the security team form D (appendix D).

5.6.3.5 Training

Induction training is provided for all security leads to be able to add and remove colleagues from fingerprint access system (FAS).

5.6.4 Procedure for accessing Amber Lodge using the fingerprint system

1. Place your allocated finger on the fingerprint reader outside the main entrance.
2. Once the reader has successfully registered your fingerprint, it will bleep twice and the door will be released from the magnets allowing you to push the door open.
3. Once through the door access your personal alarm by entering the code into the storage panel and remove an alarm tag. Ensure the alarm tag is fully charged, flashing green following the green button being pressed. Attach the alarm to your person.
4. Use the internal fingerprint reader to the left of the ward door to gain access to the main ward in the same way as the entrance to the building.
5. Once on the ward go directly to the colleague locker rooms and place all personal belongings, including all restricted and prohibited items, into the lockers provided.
6. From the colleague locker room proceed to the key tracker room and follow the procedural guidance as detailed in the accessing keys from the key tracker system, Amber Lodge procedure.

5.6.5 Procedure for leaving the building

1. When leaving the building follow the guidance in the accessing keys from the key tracker system to ensure safe return of all keys, Amber Lodge procedural document.
2. Retrieve personal possessions from colleague locker rooms.
3. Enter airlock utilising the fingerprint readers by the door.
4. Return personal alarm fobs to the panel.
5. Leave the building utilising the fingerprint reader to the left of the door.

5.6.6 Contingency plan in the event of failure of the fingerprint access system

In the event that the fingerprint access system (FAS) fails to work, either for an individual or if the full system fails, colleagues are to revert to accessing the areas of Amber Lodge manually with keys. Access and egress to the unit will be managed by the reception colleagues or if out of hours an identified security lead will be nominated to fulfil these duties.

Any failure of the fingerprint access system must be escalated through the line management structure and reported for repair as a matter of urgency.

5.7 Forensic digital content and devices

5.7.1 Aim

To create a safe and structured way of increasing patients access to the internet which will promote communication and contact between patients and their families and friends, build on technical skills, independence and promote rehabilitation and recovery.

The policy is designed to ensure that the service can respond safely and effectively to patients needs and changing technologies and ensure that national standards for low-secure services are met.

The policy aims to prepare patients, who may have lived in a secure setting for a long time, for modern day community living. To achieve the above, the trust has funded individual iPads for each patient on Amber Lodge.

All guidance within the document considers specific Ministry of Justice (MoJ) restrictions that may be in place for individual patients detained under section 37/41 of the Mental Health Act.

5.7.2 Scope

This document applies specifically to the forensic service and provides procedural guidance for use of colleagues working in this service including agency, bank and students.

5.7.3 Procedure

Assessment for use of internet and technology
Each patient will be assessed by the multi-disciplinary team (MDT) to decide on the appropriate level of internet use based on risk. This will be completed on an individual basis and included as part of the patient’s care plan. Some patients will have restrictions (internal and external) which may limit or include supervision or no access to certain types of technology (social media). The multi-disciplinary team will provide a rationale for any restrictions and provide education and support in respect of the risk to them or others around the use of internet and technology.

5.7.3.1 The process for increased internet access or access to technology

1. Patient request or professional recommendation for iPad, smartphone, or other technological device.
2. Request is reviewed in multi-disciplinary team meeting.
3. Patient to complete IT education booklets with social worker (including social media, getting a phone and email and shopping booklets). Social worker to agree timeframe with patient for completion of the booklets.
4. Review work completed in multi-disciplinary teams any other business to agree request.

5.7.3.2 Agreed and prohibited devices and applications

The multi-disciplinary team have formed a brief list of agreed and prohibited technological device and applications with the aim of promoting patients’ care and treatment whilst at Amber Lodge and managing risk to themselves and others. The list is not exhaustive; any other requests will be discussed on an individual basis with the multi-disciplinary team.

5.7.3.2.1 Devices

Agreed:

• phones (basic and smartphones)
• iPads (including apps)

Prohibited:

• Sky
• broadband
• any memory device (including USB memory sticks, dongles and SD cards)
• smart TVs
• patient’s own devices (excluding agreed smartphones)
• gaming consoles with internet connection

5.7.3.2.2 Applications

Agreed:

• banking
• YouTube
• transport (for example, Travel South Yorkshire, Trainline)
• Facebook (excluding Messenger)
• online shopping (for example, Amazon)
• food delivery (for example, Just Eat)
• HMRC
• Netflix
• quiz apps
• video (for example, Zoom, Microsoft Teams or Skype)
• emailing (for example, Outlook)

Prohibited:

• TikTok
• Snapchat
• WhatsApp
• Facebook Messenger
• Instagram
• anything which requires a TV licence (for example, BBC iPlayer)
• gambling apps

5.7.3.3 Emailing

Patients will be supported to create individual email accounts is approved by the multi-disciplinary team. The email address must be appropriate and be identifiable to the patient (for example include their name or initials) and be agreed in multi-disciplinary team on a person-centred basis prior to the account being made. The email address will be subject to random checks which will be included in the patient’s individual care plans. Patients should ensure that they log out of their email account after each use.

5.7.3.4 Website access

Some patients who present a high level of risk will have an approved list of websites that they can access.

Patients are not permitted to accessing the dark web or any other illegal websites. Should this occur, it will be reported to the police without delay.

Patients are not permitted to access any websites of a sexual nature or adult nature whilst using the trust devices.

All items ordered on the internet will be subject to security procedures on arrival at the unit and if contraband items are found, they will be stored securely until discharge.

Patients should never delete the browsing history, as this will be subject to checking by colleagues on a regular basis.

5.7.3.5 Social media

Patients should only access social media if agreed by the multi-disciplinary team. Patients must provide colleagues with their profile and, or username and passwords, and patients social media will be checked by colleagues on a regular basis.

Patients should only add or follow others who have been approved by the multi-disciplinary team. Patients are not permitted to make unsolicited contact or search other profiles who do not wish to receive contact.

Patients must ensure they have logged out of their social media accounts after each use.

5.7.3.5 Prohibited internet use

• Accessing, sending or posting content that may cause distress to another individual intentionally or otherwise.
• Accessing, creating, sending, sharing any post or material (including information, question or opinions) which is libellous, pornographic, sexually explicit, obscene, indecent, or extreme or which is discriminatory, harassing or includes hostile material relating to gender, sex, race, sexual orientation, religion, disability or may incite hatred violence terrorism or any illegal activity.
• Sending any communications other than from multi-disciplinary team approved individual personal email that much be identifiable to the patient.
•  Downloading or distributing programmes, music or films which may infringe copyright.

If a prohibited use is identified, the session will be terminated, and access suspended until an investigation has been completed by the ward team. Repeated or serious breaches may result in the patient’s internet access being permanently suspended. Any breaches that are thought to be criminal in nature will be reported to the police at the earliest opportunity.

5.7.4 Risk assessments

The use of internet and technology in forensic services are restricted as per patient’s individualised care plans. Prior to any internet access, all patients will be individually risk assessed using guidance below:

5.7.4.1 Risk example of risk guidance

Across all levels of risk (high, medium and low), patient devices will be subject to weekly trust information technology (IT) history review.

The level of risk identified for each patient is subject to review. All increased access to the internet will be discussed at multi-disciplinary team. Should there be concerns about inappropriate use of the internet, access to the internet will be suspended by colleagues.

All colleagues will have iPad training sessions with trust IT service to support them with basic knowledge of navigating such device, and to increase awareness of recognising inappropriate internet use which could compromise safety and security.

5.7.5 Safeguarding

All patients will receive an individual log in to access the trust’s Wi-Fi. This will enable monitoring of internet usage by weekly information technology (IT) history checks and enable any illegal activity to be attributed directly to the individual.

All colleagues will be supported by visual easy read guides, to enable them to competently check devises (iPad and smartphones). Patients will be limited to purchase iPhone or Android devices only, to ensure that colleagues are able to navigate the searching of devices for the protection of the patients and others.

Devices cannot be shared between patients. The iPads will be individually allocated and identifiable to each patient; this will be achieved by marking each iPad with an ultraviolet (UV) pen.

Patients will only be allowed unsupervised access to iPads or smartphones (if agreed by the multi-disciplinary team) in their own bedrooms to mitigate safeguarding concerns. This is due to these devices having audio and video functionality which may be disruptive to other patients and the content may be offensive and or upsetting to some. In addition, images and recordings may be taken overtly and covertly, edited and, or shared without consent.

Patients must not live stream, as this adds a specific risk in terms of safeguarding, as it allows very little scope for intervention by professionals before the content is seen by an audience.

Patients who are allowed unsupervised access to iPads and smartphones must agree to turn their hotspot off to ensure that no other patients can access internet from their devices.

Where there are concerns relating to the patient’s capacity to consent to any restrictions being considered a capacity assessment must be undertaken and evidenced on a Mental Capacity Act (MCA) 1 form. Where the patient lacks capacity to consent and there is a risk posed, a best interest decision should be made and evidenced on a Mental Capacity Act (MCA) 2 form. Colleagues should seek further guidance from the trust’s Mental Capacity Act (MCA) (2005) policy.

Where there are specific concerns about the patient’s capacity around use of social media and the internet, a separate assessment of capacity should be undertaken.

It is a breach of relational security for patients to attempt to contact colleagues on social media or by other means online and for colleagues to accept these from patients or members of their family. Any breach will result in suspension of the device until review by the patient’s responsible clinician in the next monthly multi-disciplinary team meeting.

Should any patient not have a mobile phone, there is access to a telephone during their stay. On Amber Lodge there is a private telephone room available to all patients. Calls are connected by the trust switchboard then charged to the individual by the finance department. Calls to solicitors, social workers, care coordinators etc. are free of charge.

Once a patient is discharged from the service, any devices belonging to the trust will be sent to the IT department to be re-set. Any intentional damage to trust devices will be discussed within the patient’s multi-disciplinary meeting and an outcome and, or action agreed.

5.7.6 Security

Colleagues and visitors are requested to leave mobile phones and other devices in the lockers provided when entering the forensic wards.

Colleagues will carry out weekly environmental checks around the ward to review any ability to detect “hot spots” from any areas surrounding Amber Lodge.

Patients will not be allowed any unsupervised access to trust devices due to the risk of accessing confidential information.

5.8 Patient escape from amber lodge forensic services

5.8.1 Aim

The aim of this document is to provide service specific guidance for colleagues who work in the forensic service when dealing with an escape situation to ensure effective management and reporting of the incident.

5.8.2 Scope

This document applies specifically to the forensic service and provides procedural guidance for use of colleagues working in this service including bank and students.

5.8.3 Procedure

5.8.3.1 Definition of escape

A detained patient escapes from a unit or hospital if he or she unlawfully gains liberty by breaching the secure perimeter that is the outside wall, fence, reception or declared boundary of that unit.

5.8.3.2 Action to be taken if a patient goes absent without leave whilst an inpatient in the forensic service

• Colleagues must immediately notify the nurse in charge.
• Colleagues are to inspect and review all safety and security checks ensuring these are completed fully.
• Colleagues are to notify switchboard as they may receive calls with regard to the missing person.
• If any damage is discovered ensure the environment is made safe immediately, for example, remove debris, lock off the area if this is required, following the blanket restrictions policy for this and report accordingly.
• Colleagues should remain in the area that is damaged at all times until fully fixed to ensure no further incidents of escape can occur.
• Ensure no other patients are able to access the site of escape.
• If possible take photographs of the area of egress including any damage caused.
• Report damage to estates for inspection and repair as a matter of urgency.
• As the patient has exited the external perimeter they are now officially absent without leave so the nurse in charge of the shift at the time of the escape is to take responsibility for implementing the trust patients missing or absent without leave (AWOL) policy.

5.8.3.3 Action to be initiated

• Notify the police immediately and complete a missing person police form, making clear the patient’s legal status, the multi-agency public protection agency (MAPPA), Ministry of Justice (MoJ) and the Mental Health Act (MHA) Office, ensure all identified risks and potential whereabouts if known are communicated.
• Notify the patient’s responsible clinician who in the case of restricted patients will notify the Ministry of Justice during normal working hours. Out of hours contact the on call consultant.
• Notify immediate management within working hours and the on-call manager for escalation out of hours.
• If applicable notify the patient’s next of kin as the patient may contact them.
• Record all actions completed in the patient’s electronic record, SystmOne. This must be contemporaneous and reflect the timeline of actions as documented on the report for the patient’s commissioning bodies.
• Report the incident on the electronic trust system, Radar.
• In the event that the patient does not return to the ward by midnight on the first day of absence complete and email the absent without leave notification form to the Care Quality Commission. Then send the original to the service manager, matron, or Mental Health Act office.

5.8.3.4 Action to be taken if there is an identified risk to another person or persons in the event of a patient escaping

Colleagues are to refer to the patient profile, which can be found at the front of the patient’s file as per business continuity planning. Information will be included in this patient profile detailing person or persons who may be at risk in the event of a patient escaping and being absent without leave. Colleagues are to use this information to:

• notify identified people at risk from the individual as detailed in the risk assessment and management plan that the patient has left the unit unsupervised
• identify any victim issues that need to be taken into account and liaise with police and the victim liaison officer, informing them as appropriate
• if subject to multi-agency public protection agency (MAPPA) notify the agency of the situation
• notify the Public Protection Unit (PPU) and assigned officer if applicable
• if there are identified child or adult safeguarding issues notify the appropriate social service or outside or normal working hours the duty social worker.
• notify switchboard who may receive calls with regard to the missing person
• include this information when completing accurately the trust incident reporting system

5.8.3.5 Action for ward colleagues to take if the patient has not returned to the unit by midnight on the first day of absence

• In the event that the patient does not return to the ward by midnight on the first day of absence complete and email the absent without leave notification form to the Care Quality Commission. Then send the original to the service manager, matron, or the Mental Health Act Office.
• All pertinent information can be found on the patient profile document stored at the front of the patient file which is required for business continuity purposes.
• Report to the responsible clinician if they have not yet been made aware.

5.8.3.6 Action to be taken when the patient returns

• Facilitate assessment of the patient and consider a rub down search, drug and alcohol testing if clinically indicated or required as part of the patient’s risk management plans.
• Suspend any further section 17 leave until a full multi-disciplinary team review has been undertaken with the responsible clinician.
• Modern matron to inform patient commissioning bodies and initiate an after action review and share learning as appropriate.
• When a detained patient who absconds has been reported to the Care Quality Commission and returns, part two of the absent without leave notification form is to be completed and emailed to the Care Quality Commission and a copy to the Mental Health Act office to them (see appendix O).

5.8.3.7 Action to be taken as soon as possible or during the next working day

• Undertake a full comprehensive inspection of the environment inclusive of the area used as means of escape with the trust’s local security management specialist, patient safety lead and estates lead.
• Escalate internally to all of the senior leadership team.
• Ensure any identified works that are needed are or have been reported to the estates department.
• Review and update as appropriate all risk management plans for patients ensuring high risk patients are prioritised. Liaise with commissioner for “red flag” patients as appropriate.
• The multi-disciplinary team are to continue to review the patient who has escaped considering care pathways, discussing with the case manager if medium secure is to be considered.
• Request a critical friend review from another secure care provider and action any recommendations from this.
• Complete a serious incident investigation as per trust policy if not already completed.
• Arrange urgent forensic service incident control meeting consisting of trust leads and senior management team.
• Twice weekly meetings are to be undertaken to ensure all urgent actions are completed and signed off by all stakeholders.
• Inform patient commissioning bodies and all documentation as required.

5.9 When a patient goes absent without leave (AWOL)

5.9.1 Aim

The aim of this document is to provide service specific guidance for colleagues who work in the forensic service when dealing with an absent without leave (AWOL) situation to ensure effective management and reporting of the incident, meeting the requirements of the Care Quality Commission (CQC).

5.9.2 Scope

This document applies specifically to the forensic service and provides procedural guidance for use of colleagues working in this service including bank and students.

5.9.3 Procedure

5.9.3.1 Definition

The term absent without leave (AWOL) in the forensic service is defined by the NHS secure commissioners as “any situation where patients are absent without agreement or planned leave or have not returned from leave”.

5.9.3.2 Action to be taken if a patient goes absent without leave whilst an inpatient in the forensic service

• Colleagues must immediately notify the nurse in charge.
• Organise an immediate search of the surrounding area.
• Notify switchboard of the absent without leave (AWOL).
• If the search is unsuccessful, notify the police immediately and complete a missing person (police form), making clear the patient’s legal status, multi-agency public protection (MAPPA) status and identifying all risks and management plans.
• Notify the responsible clinician and management team during working hours.
• Notify the Mental Health Act (MHA) office and if applicable the Ministry of Justice (MoJ) of the absent without leave.
• Instruct the provider collaborative: scn-tr.qualityandperformance.sybpc@nhs.net regarding the absent without leave including the case manager if known for the individual patient.
• Out of hours, contact the on-call consultant and the bronze level manager who can escalate the situation appropriately within the on-call structure within the trust.
• Notify switchboard as they may receive calls with regard to the missing person.
• Notify the patient’s next of kin if appropriate as the patient may make contact with them.
• Comprehensively record all action taken into the patient’s electronic clinical record, SystmOne.
• Register the patient as absent without leave on SystmOne.
• Complete an electronic incident report form within the Radar platform.
• In the event that the patient does not return to the ward by midnight on the first day of absence complete and email the Care Quality Commission absent without leave notification form to the Care Quality Commission. Then send the original to the service manager or matron or Mental Health Act office.

5.9.3.3 Action to be taken if there is an identified risk to person or persons in the event of a patient going absent without leave

• Colleagues must refer to the patient profile sheet which will detail identified risks. This is found in the front of the patient file, as per business continuity planning requirements.
• Colleagues will need to use the above information to inform anyone identified in the patient’s risk assessment and risk management plan of the fact the patient has left the unit unsupervised.
• Identify any victim issues that need to be taken into account and liaise with police as appropriate.
• Determine if the patient is subject to multi-agency public protection arrangements (MAPPA) and if so notify them.
• Any child or adult safeguarding issues notify the appropriate social service or duty social worker outside of normal working hours.
• Notify switchboard who may receive any calls about the missing person.
• Action to take if the patient has not returned to the unit by midnight on the first day of absence
• Complete part 1 of the Care Quality Commission absent without leave notification form and send immediately to the head of service and modern matron ensuring a copy is also sent to the Mental Health Act office for submission to the Care Quality Commission.
• Notify NHS England of the incident.

5.9.3.4 Action to be taken when the patient returns

• Complete a full search upon return to the unit
• Complete alcohol and drug testing if clinically indicated.
• It is the responsibility of the nurse or clinician in charge to inform everybody previously notified of the patient’s absence of their return. This includes out of hours the bronze command on call manager.
• Nurse in charge should only contact the on-call doctor outside of normal working hours about the return of an absent patient if there are concerns about the patients’ mental state or physical presentation and the medical attendance is needed.
• Suspend any further planned section 17 leave until a review can be undertaken by the responsible clinician and multi disciplinary team.
• Modern matron to instigate after action review and share any learning in the directorate and the wider trust is required.
• When a patient who absconds has been reported to the Care Quality Commission and returns, part two of the Care Quality Commission absent without leave notification form is to be completed and emailed to the Care Quality Commission and a copy to Mental Health Act Office to them (see appendix A).

5.10 Pornographic and sensitive material management

5.10.1 Aim

The aim of this document is to provide working guidance and procedures for colleagues working in the forensic service to enable robust management of pornographic and sensitive materials. There is a requirement to have clear guidance regarding pornographic and sensitive material, as there has been research undertaken which shows that pornographic material can be linked to sexual offending and the development of inappropriate sexual beliefs and behaviours. It has therefore become ‘good practice’, particularly within secure environments and with individuals who have a background of sexual offending, to manage materials that may cause harm to them or others.

It is also known that pornographic material can have a differential effect on different people and that individuals’ with mental health or mental illness problems can be affected by the nature and content of this material, particularly if they have an inappropriate sexual interest or if they have a background of being sexually abused. These issues can potentially give rise to safeguarding concerns. It is therefore important to manage and protect the patients within secure environments.

Managing sexually explicit material should aim to balance the rights of individual patients, with the requirements to maintain a safe environment within secure settings. It attempts to take into account issues surrounding the patient’s sexual needs and to be sensitive to these issues.

In regard to sensitive materials, it should be recognised that this relates to other materials, which if held or utilised by the individual, may also give rise to inappropriate behaviours related to sexual offending and which also require supervision and, or management, for example, clip art, magazine pictures of children.

5.10.2 Scope

This document applies specifically to the forensic service and provides procedural guidance for use of colleagues working in this service including agency, bank and students.

5.10.3 Procedure

Adult or pornographic materials may be in the form of:

• TV
• photographs
• magazines
• DVDs
• videos
• posters
• papers
• phone
• texts
• internet

However, the content is relevant to each individual’s preferences or risk profile and will need to be indicated or identified in the individual’s care plan and may not necessarily be of a sexual nature.

The use of pornographic material and sensitive material in forensic services is restricted as per patient’s individualised care plans.

Pornographic material and sensitive material are listed within the procedural document “prohibited and restricted item management”.

A full risk assessment will be completed on each individual patient and access to sexually explicit materials will form part of this. Colleagues will check material prior to patient’s having access to ensure the material does not breach individual care plans. This will be done discreetly.

The storage of such items will be detailed in the patient’s individualised care plan.

Pornographic or sensitive material cannot be brought into communal areas and cannot be shared or discussed with other patients.

No illegal sexual material will be allowed on the unit. In the event of illegal sexual materials being found on the unit, these would be removed and placed in a secure locked cupboard and the police would be informed and asked for guidance.

The following items are not acceptable in any circumstances:

• any material which is copied; illegally copied or illegally recorded by any other means, which breach copyright law and therefore cannot be measured in terms of legality
• any item which would not be available to the general public other than through a specialist supplier or import company
• anything contravened by the Obscene Publications Act or the British Board for Film classification guidelines

5.11 Prohibited and restricted item management

5.11.1 Aim

The forensic service aims to provide a safe environment for patients, visitors and colleagues.

Patients will have access to their personal possessions where appropriate. However it will be necessary to exclude or restrict some items from patients while they are resident at Amber Lodge.

Prohibited items are excluded because their makeup or properties are hazardous. This may be because they could be used to harm others; because of their harmful properties (for example, drugs or alcohol) or their intrinsic illegality (for example, child pornography or illicit drugs).

Restricted items may also be potentially hazardous. This may be because they could be used to; cause distress, to self-harm or to harm others. These items may be restricted but not prohibited because they can be valuable tools in encouraging normalisation and avoiding institutionalisation, providing opportunities for rehabilitation, social inclusion, recreation and diversion.

Access to restricted items will depend on many factors, some may be fixed and others subject to change. For items that may be considered for restricted use, colleagues should complete a thorough risk assessment in collaboration with the multi-disciplinary team, and patients family and carers where appropriate. The risk assessment should include:

• person risk (individuals’ historical risks and current mental health state
• interpersonal risk (direct risk to others/patients and colleagues)
• environmental risks (ward dynamics and general service safety)
• common sense consideration of the item in question. 2019 Care Quality Commission brief guide on the use of blanket restrictions in mental health wards

To ensure a safe therapeutic environment is maintained, for all patients, colleagues and visitors at Amber lodge.

This procedure describes the processes by which we will ensure best practice for the care and treatment of those using the low secure service and compliance against national standards for low secure services, whilst adopting the ethos of least restrictive practice.

5.11.2 Scope

This document applies specifically to the forensic service and provides procedural guidance for use of colleagues working in this service including agency, bank and students.

5.11.3 Procedure

In the interests of health, safety and security, there are certain items which could pose a risk to the patient or colleagues on Amber Lodge. Notices detailing prohibited and restricted items are displayed in the air lock of Amber lodge (appendices G and H).

We therefore ask that visitors do not bring the items listed in section 4.1 onto the unit. All visitors prior to entry to the ward will be asked to store any prohibited or restricted items within the visitors lockers available in the airlock.

5.11.3.1 Prohibited Items

• Alcohol.
• Blu-Tack.
• Cans.
• CD’s or blank DVD’s.
• Chewing gum.
• Drones.
• Fidget spinner.
• Fire hazard Items, lighters, matches etc.
• Illicit or illegal substances.
• Laser pens.
• Equipment that can record moving or still images.
• Radio scanner.
• Recordable devices.
• Rope.
• Plastic bags.
• SD cards.
• Weapons of any type.
• Wire hangers.
• Wire-bound books.

This list is not exhaustive.

5.11.3.2 Restricted items

• Aerosols.
• Basic and smartphone mobile phones.
• Energy drinks.
• Glass items.
• Glue or solvents.
• Identification.
• Laptop or tablets or USB.
• Money including bank cards.
• Needles or syringes.
• Photography equipment.
• Razors wet or dry.
• Scissors or cutting equipment.
• Steel toe-capped boots.
• Vehicle or house keys.
• Fidget spinners.
• Items of stationary.
• Cutlery.
• Tinned materials.

This list is not exhaustive and needs to be aligned with the trust blanket restrictions policy.

On admission, patient’s property will be searched by colleagues as per the trust searching of a person or their property policy and any prohibited or restricted items will be removed and returned on discharge (depending on the nature of the restricted items). If any items are removed the details will be recorded into a duplicated Removed Items book (in line with the forensic service searching of a person, (patients and visitors) and their property procedure). A duplicated copy will be given to the patient as a receipt, one will remain in the book and one will be filed into the nursing care file for that patient. Under no circumstances will any unknown or illicit substances be returned to the patient. To dispose of any illicit substances, staff should follow the procedure outlined in the drug misuse on trust premises policy.

To dispose of weapons colleagues should contact the police for guidance. All removed items will be securely labelled and stored until their use is approved, or the patient is discharged or transferred from the unit. An explanation is to be provided to the patient of the reasons for this removal.

All visitors are required to leave all personal items included on the restricted items list in the lockers provided. This is to maintain the security of the unit, and for the safety of colleagues, patients and other visitors. Notices detailing restricted items are displayed in the unit airlock area. Any food or drink brought in by visitors must be shop bought, sealed and within its sell by date unless by prior arrangement with nursing colleagues.

Sharp objects held within the unit must be recorded as per the security Amber Lodge procedure.

Restricted items that patients have been granted access to by the multi-disciplinary team (MDT) must be stored in a secure cupboard within the service with nursing colleagues’ oversight and management. Any access to restricted items agreed by multi-disciplinary team will be individually care planned.

Patients are assessed by the multi-disciplinary team to establish the amount of money (for example, cash) they are able to hold on their person and in their personal bedroom safe. This also includes access to bank cards.

If colleagues suspect that a patient is in possession of either a prohibited item, or a restricted item not previously agreed, the following steps should be taken:

• the nurse in charge will ask the patient to hand over the items to them and any patient’s leave may be suspended if required until discussed at multi-disciplinary team review dependent upon the items retrieved
• carry out personal or room search as per searching of a person, (patients and visitors) and their property procedure)
• inform responsible clinician and modern matron immediately

5.12 Searching a person, (patients and visitors) and their property

5.12.1 Introduction

We search to deter, prevent and detect, unsafe activities, by removing unauthorised items from patients; we may disrupt undesirable activities that limit opportunities to escape, harm others or harm themselves. A search can also gain intelligence in order for the trust to deliver a higher standard of care.

Ultimately, search techniques provide a systematic procedure for finding articles which may present a threat to the safety of people or property, or which adversely influence the control of a ward area, thus disrupting the hospitals therapeutic task (Elvin 1989).

The searching of a person or their property is not routine and, as such, should only be carried out in exceptional circumstances, for example, where the dangerous or violent criminal propensities of patients create a self-evident and pressing need for additional security (Department of Health 2008). In such circumstances, nursing staff have a statutory duty to provide both a safe and therapeutic living and working environment for patients and staff and to protect the public. Therefore, searches are an essential and justifiable component for safe practice.

This procedural document takes into account guidance issued within a number of documents, including the Short-Term Management of Disturbed or Violent Behaviour in Psychiatric Inpatient Settings and Emergency Departments (NICE, 2005), and the Memorandum of Understanding between the Association of Chief Police Officers (ACPO) and the NHS Security Management Service (2006). It also follows the clear principles laid out within the Code of Practice Mental Health Act 1983 (section 16.11), which are:

• to create and maintain a therapeutic environment in which treatment may take place and to ensure the security of the premises and the safety of patients, staff and the public
• the authority to conduct a search of a person or their property is controlled by law, and it is important that hospital staff are aware of whether they have legal authority to carry out any such search
• searching should be proportionate to the identified risk and should involve the minimum possible intrusion into the person’s privacy and dignity
• to undertake all searches with due regard to, and respect for, the patient’s dignity

5.12.2 Aim

The aim of this document is to work in line with the Mental Health Act (MHA) code of practice requirements to provide a working procedure on searching patients detained under the Mental Health Act (1983), their belongings, surroundings, and their visitors (Code of Practice Mental Health Act (1983) section 16.10). This document provides guidance which is specific to the forensic service for all staff who are required to carry out both proactive and reactive searches.

5.12.3 Scope

This procedure applies to the searching of a person, (patients and visitors) or their property and is specific to the staff working within the forensic service who may need to undertake proactive or reactive searching.

5.12.4 Responsibilities, accountabilities and duties

In addition to the overarching responsibilities, accountabilities and duties as detailed in the forensic manual, the following professionals have the additional responsibilities as detailed.

5.12.4.1 Senior sisters or ward managers, sisters or deputy ward managers

The managers of the unit have the frontline responsibility for ensuring that:

• the principles and practicalities of the procedure are embedded within nursing practice
• training is attended by nursing staff where required
• care plans around searching are audited and reviewed with patient involvement where appropriate
• search equipment is readily available for effective searches to be carried out to deter, prevent and detect unwanted risk on the ward (see information detailed in appendix L, security box inventory)
• It is the responsibility of the senior sisters to bring any issues around searching to the modern matron

5.12.4.2 Named nurse

It is the responsibility of the named nurse, where justifiable and appropriate, that search care plans are written with the patient, and include:

• level of compliance in searches, both historic and current
• the highlighted areas of risk concern, with reference to appropriate risk assessments, for example, HCR20 or SVR20 or RSVP or FACE
• any contraband or concerned items found, both historically and more recently
• multi-disciplinary team (MDT) involvement in the care plan
• the patient’s level of insight into the risks
• any religious or cultural guidance for staff, if appropriate to the individual, in relation to searching, this should include consultation with relevant communities
• an attached form that highlights the dates and times of previous searches and provides a quick guide for staff; it is important, however, that planned proactive searches (planned randomly) are not added to the chart for patient access

It is important that the care plans are robustly reviewed, and that any concerns are highlighted in the review, for example, volumetric control is fed back to multi-disciplinary team for guidance. It is also important that named nurses are responsible for ensuring that patient inventories (clothing and belongings) are up-to-date and are reviewed regularly with the patient’s special interest workers. An up-to-date patient inventory will act as support during a room search if any unknown patient items are found in rooms.

5.12.4.3 Shift co-ordinators

Qualified nurses as shift co-ordinators must have an understanding of the current care plans in place, have the knowledge and competence required around the carrying out of searches (both proactively and reactively) and risk, and are to be able to take the lead in organising this in a timely manner. Therapeutically, it is the responsibility of the shift co-ordinator to bring any issues around searches to the notice of the senior sister, sister and responsible clinician, where appropriate.

5.12.4.4 All nursing staff

All nursing staff have a responsibility to conduct their practice in line with this procedural document and in accordance with the Mental Health Act (1983) and its code of practice. Staff must attend any training which is provided to promote its implementation and bring any issues regarding searches to the shift coordinator, senior sister and sister.

5.12.5 Procedure

5.12.5.1 Room search

On occasion, either proactively or reactively, rooms within the building may require searching. The need to search bedrooms and their local environments is, in principle, for the same reason of detecting, deterring and preventing risk. However, the searching of a patient’s bedroom requires a personalised approach, the ability to understand the differing risks that each bedroom may present, and how searching can also provide a means of gathering intelligence or information on a patient during a search.

If when the patient is asked for permission, this is not given, then it is important that a conversation is held with the patient to attempt to seek out the reasons for refusal. If the patient continues to refuse, then the responsible clinician is to be contacted for further advice. In the meantime, unsupervised access to the patient’s bedroom is to be prohibited and, where possible, access locked off.

It is important that a room search is carried out with the correct prior planning. It is essential that our staff are professional, approaching and acting in a manner that shows empathy and respect for the patient’s feelings and property.

5.12.5.2 Room search (with or without patient consent)

It is important, prior to the search being carried out, to ask the patient if they have any restricted or prohibited items in their room, see appendices G and H. Once the room search is organised, the patient is to be advised of the search in an appropriate place, for example, visitors room to allow privacy.

The patient is not to re-enter the bedroom once this information has been handed over. However, where possible, neither should the search be delayed after the information has been passed to the patient.

If they so wish, the patient may be in attendance whilst the room search is carried out. Prior to the room search the patient will have a rub-down search (see section 6.2). The patient will be asked if they have any items of value (including religious items). If yes, these items will be searched first before being handed back to the patient.

If the patient chooses to be in attendance it is important that they remain sat outside the bedroom, allowing them sight of the search whilst ensuring the search is carried out within the same sterile environment from the point that staff enters the room to begin the search. Staff should also have a clear exit out of the room.

Ensure that the search box is readily available prior to the search being carried out. The inventory of the search box should be checked, in addition to checking that the equipment, for example, torch or search wand, is in working condition. Standard personal protective equipment (PPE) equipment will be readily available in the box, for example, gloves and aprons.

However, the searching staff are to ensure, where appropriate, that extra PPE equipment is available, if any risks are highlighted within the patient’s individual search care plan or if any risk is highlighted either prior to, or during, the search.

The search will be carried out by two members of staff, one of whom will be the same gender as the patient. The other will be a registered nurse.

The registered nurse will be responsible for leading the room search. It is preferable that either the registered nurse, or the same gender staff member, has attended the divisional forensic enhanced search training.

It is essential that, prior to searches being carried out either proactively or re-actively, that individual care plans are read thoroughly and that both searchers have a good understanding of the individual’s current and clinical risk, whilst also taking into consideration any cultural and, or religious beliefs.

The room search is to be carried out in a systematic fashion, for example, starting from top to bottom, left to right, breaking the room down into agreed segments and ensuring that all areas are adequately searched.

It is paramount, however, that the searchers do not check any areas with their fingers which they cannot visibly see, this is to protect them from potential harm. Searchers are to use the search mirror (available in the search box) for these areas.

The staff member leading the search will be agreed prior to the search commencing and will commence the room search, with the second staff member. Identifying areas within each segment or area to be searched will be completed first. The items in each segment, including loose furniture, will be moved (where possible) to the middle of the room and searched prior to being placed back. Reasonable effort is to be made to replace items as they were originally found.

It is important that the room search is continuously carried out by two members of staff, as this will be key if any allegations are made, assaults attempted, or if any damage is reported or found or accidentally caused during the search.

Any issues around search fatigue, for example, if a search is taking over 2 hours, are to be discussed with the lead searcher and, if required, staff are to be given the opportunity to swap. It is important however that wherever possible, one of the original searchers remains, to ensure consistency and continuity.

If any items are required to be removed from a room during a search, the patient or visitor is to be given a receipt for the items removed, and an explanation is to be given as to why. Details for ordering a receipt booklet can be found in appendix K.

In circumstances where damage is caused during the room search, this must be reported, with any damages caused maybe being replaced.

If any portable devices, for example, PlayStations, memory sticks, are unable to be checked at the time, then it is imperative that these are removed for checking. If the devices are unable to be checked on area, then the trust IT service are available to support in searching the memory of such items, and should be contacted as follows:

• log the required search as urgent
• the system will confirm and will allocate the search an assignment number
• the item to be searched will be forwarded to second line desktop at Chestnut View
• Chestnut View will contact the area with a date and time for the device to be delivered
• staff to attend Chestnut View on the date and time given and remain present during the search of the item, any evidence, for example, printing of the memory contents is to be carried out at this time and the item returned to the ward
• any contraband or concerns identified within the search are to be fed back to the responsible clinician

At the end of the search it is important, and of therapeutic value, that the patient’s compliance during the search is acknowledged by the searchers. At this point, a post-incident review is to be offered to the patient, both consenting or not.

The outcome of the room search will be conveyed to the responsible clinician, detailing the length of time of the search, the level of compliance from the patient, a general description of the bedroom searched, for example, clean and tidy, a list of items removed (if any), the reasons why and also any intelligence gathered. This information is also to be documented within the patient’s electronic records and updated within the individuals care plan. Any further action required will then be decided by the responsible clinician or ward manager, out of hours the manager on call.

It is noted, and staff are to be mindful when carrying out room searches, that patients restricted mail, for example, tribunal letters and Ministry of Justice correspondence, can be searched but is prohibited from being read.

5.12.5.3 Full ward search

It may at times be necessary to conduct a full ward search. Prior to this being initiated the nurse in charge will contact the ward manager or out of hours manager on call to obtain authorisation. The ward manager or manager on call will coordinate the implementation of the ward search including procuring any additional resources (including staffing). Please also refer to lockdown of a trust premise, site or building policy and procedures.

5.12.5.4 Rub-down search

Rub-down searches can be carried out either pro-actively or reactively.

Proactively with justification around areas of risk that will be agreed and implemented through a care plan.

Reactively in circumstances whereby highlighted risk deems that a search must be completed to prevent harm to the person, others, or members of the public.

As a minimum, two staff members are to carry out this procedure, one being a registered nurse and the other being required to be the same or identified gender as the patient or visitor.

It is essential that the person who will be physically searching the patient or visitor is of the same or identified gender as the patient or visitor. If, in extreme circumstances, there is not a male colleague on the ward, then male colleagues are to be temporarily redeployed to carry out the search. The role of the second colleague is to observe the procedure as support for the staff member carrying out the rub-down search.

Prior planning is important before commencing the search. The searching colleagues are to ensure that the search box is readily available and that all required equipment is in working order.

Where appropriate, the searching colleagues are to have completed the search training.

The searching colleagues are to ensure that an appropriate room, for example, the visitors room, is readily available for the search. This is to promote privacy, whilst also allowing an appropriate amount of space to carry out the rub-down search.

When appropriate, the patient should be asked to move to the appropriate area for the search to be carried out. Under no circumstances is the patient to be given prior warning of the search, as this could give them the opportunity to remove any items from their person.

It is essential that, prior to the search being carried out, the patient is asked whether they give permission for the search to be carried out.

Upon permission being given, the individual is to be asked whether they have any contraband items, or items of concern, upon their person. If patient is not consenting, colleagues are to discuss immediately with the responsible clinician and multi-disciplinary team.

It is important that, from the commencement of the procedure, the staff empathise with the patient, have an understanding of the procedure being carried out upon the patient and, where possible, maintain a therapeutic level of engagement with the individual, to promote both therapeutic working and to minimise the level of risk, where possible.

Once permission is granted and any contraband items discussed, then where relevant, the patient should be asked to remove any watches and outer wear, empty their pockets and remove shoes.

Colleagues are to ensure that the patient is asked to remove any religious or medical headwear, for example, Sikh turbans or wigs, and that they are encouraged to remove these themselves. Colleagues should search these items and allow the patient to put them back on at the earliest opportunity, and prior to the rest of the search being carried out.

At this point, the patient can be searched in a systematic manner, using the hand held metal detector from top to toe and section by section, as detailed in the flow chart (appendix J).

Once the search has been carried out using the search wand, it is then to be repeated (again, as detailed in the flow chart appendix J), with the searcher using their hands, as below, rubbing down on the clothed body.

Colleagues are not to rub-down areas of bare skin, for example, if the patient is wearing a t-shirt, as these areas are visible to the eye.

Once this has been carried out, a thorough search is to be made of any items removed, for example, shoes, watches.

The searching colleagues are to pay particular attention to items such as watches, which can have additional built-in devices, for example, lighter or cameras, recording devices.

Colleagues are to ensure that receipts are given to the patient if any contraband or items of concern were removed from them.

Outcomes of the search are to be documented within the patient’s electronic record.

If in any situation a patient either refuses a rub-down, or a rub-down has been carried out, but staff still have concerns regarding a secreted item which they have been unable to detect during the rub-down, then the responsible clinician should be contacted for further advice at the earliest opportunity.

Currently, the low-secure forensic service colleagues are not trained to carry out any higher-level searches, for example, body searches.

There are occasions, however, when staff will have to carry out a rub-down of a patient under restraint. Currently, nursing staff are able to carry out this search after completing the mandatory prevention and management of violence and aggression (PMVA) training. This may be deemed necessary, following discussion with the responsible clinician, if the patient does not give permission or during occasions of restraint if a patient requires secluding.

At the end of the rub-down search where permission was given by the patient, the level of the patient’s compliance should be acknowledged by the searchers. A post-incident review is also to be offered to the patient.

5.12.5.5 Floor restraint searches

This method of searching should only be used in exceptional circumstances, such as prior to the seclusion of a patient, and will only be conducted after the patient’s early warning scores (EWS) have been completed, and the patient is in the supine (face up) position.

1. Once the patient is in supine restraint, the lead person will ask the patient if they have any items on their person that are illegal, dangerous or restricted.
2. The patient should then be informed that they will be searched.
3. A staff member of the same gender as the patient will then begin the search, initially using the metal detector wand or glove.
4. The search will be conducted in a systematic or logical order, for example, starting at the head and working down one side, and all areas such as pockets, collars, cuffs, hair, waistbands, socks and shoes etc, are to be searched.
5. Once the search has been completed on one side, the staff member conducting the search will move to the other side of the patient and the staff who are undertaking the restraint will be required to adjust their position to allow easy access to the patient for the search to be completed.
6. Wherever possible, the staff member conducting the search is to avoid leaning over the patient to search their other side, as this can be intimidating for the patient.
7. Staff are not to put their hands into any pockets, and should use equipment such as tongs to pull anything out.
8. If the search is being undertaken prior to seclusion, then the patient’s shoes, socks, belts etc. are to be removed, as per the procedure for the secluded or segregated policy management of a secluded or segregated patient.
9. Once the metal detector search has been completed, a rub-down search should be conducted over the same areas previously searched, in order to pick up on anything that is not metal and so overlooked in the previous search.
10. Throughout the search, the lead nurse should be constantly reassuring the patient and keeping them informed as to what is happening and why.
11. Once the supine search has been completed (this can take as long as it needs to take, do not rush it, as both patient and staff should be safe and secure in this position), the clinical team can consider whether a search of the patient’s back is required.

5.12.5.6 Action if a search of the patient’s back is felt necessary

1. The patient should not be turned into a prone position to conduct a search of their back.
2. The restraint team should turn the patient onto their side to conduct a search of their back (the restraint can still be maintained during this time).
3. The patient can then be turned onto their opposite side, if required, to ensure that a thorough search is undertaken.
4. Once the patient is on their side, a full metal detector search can be completed of their back (this may require adjustments from the restraint team) followed by a pat-down search.
5. It is important that, during the search, staff are mindful of the physical monitoring (EWS) of the patient (as per trust policy) and, if necessary, the search can be halted in order to complete this.

5.12.5.6 Documentation

A comprehensive record of every search, including the reasons for it and details of any consequent risk assessments, should be made. (Code of Practice Mental Health Act (1983)).

In all cases the following action must be taken by the nurse in charge as soon as possible after the search has taken place, and before the end of their period of duty.

1. Complete and submit an electronic incident form (IR1).
2. Complete the record for when a search is carried out (see appendix I) and file in the patients clinical records.
3. Explain to the patient that any illicit or dangerous items will be disposed of and not returned to them upon discharge.
4. For any other items removed, the patients’ monies and property procedure must be followed.
5. The nurse in charge is to ensure that the patient or staff debrief be carried out on the template attached within the appendices M and N.
6. Where a patient’s belongings are removed during a search, the patient should be given a receipt for them and told where the items will be stored (Code of Practice Mental Health Act 1983).
7. The nurse in charge will make a decision regarding any level of observation the patient may require if appropriate and record this in the patient’s clinical record once the search has been carried out. This is to be assessed on an individual basis.
8. The patient’s risk assessment and care plan will be amended accordingly, if appropriate, and if changes are required to be made.
9. Inform the patient of the listening and responding to concerns and complaints policy (formally complaints handling policy), should a patient wish to make a formal complaint in relation to the search.

5.12.5.7 Action to be taken if a visitor is suspected of possessing a dangerous item, drugs or alcohol

1. The nurse in charge will discuss staff suspicions with the person concerned, explaining why the items are not allowed onto the ward and ask them to hand in anything they may have on them.
2. If they deny having anything on them, the nurse in charge will ask the person if they will consent to having their baggage and person searched.
3. If they agree, staff will continue as for rub down search (6.2) search, informing the person that any illicit or dangerous items will be removed, disposed of and not returned to them. Any other items will be removed, a receipt issued and retained until the visitor leaves.
4. If the person refuses to have their baggage and person searched, staff will deny them access to the ward and ask them to leave, explaining their reasons.
5. The patient they had come to visit will be informed why the person was not allowed access to the ward.
6. An electronic incident form (IR1) will be submitted.
7. The record for when a search is carried out is to be completed (see appendix I) and filed in the clinical records of the patient who was being visited.
8. The ward manager, responsible clinician and modern matron are to be notified.
9. A decision will then be taken whether the visitor may visit the patient. This will be a multi-professional decision lead by the nurse in charge of the ward or matron, along with the consultant.
10. When making the decision, due regard must be given to the maintenance of a safe environment for all patients and staff. The decision will be fully documented within the patient’s clinical records and will also have a process for review included.
11. Inform the visitor of the listening and responding to concerns and complaints policy (formally complaints handling policy).

5.12.5.8 Disposal of dangerous and illicit items

If the search uncovers evidence of serious criminal activity or where a need arises to preserve evidence then the items should be:

1. handled as little as possible to preserve and avoid the contamination of any evidence
2. secured in a place of safety (away from the patients).
3. the police are to be contacted and the local security management specialist (LSMS) informed
4. further advice on how to preserve evidence will be given by the Police and, or the LSMS

5.12.5.9 Alcohol removed from the patient

1. This will be disposed of by 2 staff members with the patient present, if they wish.
2. The alcohol will be poured down the sink and the bottles or cans safely disposed of.
3. A record is to be made in the patient’s clinical records indicating what was disposed of and by whom.

5.12.5.10 Prescription or over the counter drugs removed from the patient

Any medicines brought into hospital by a patient remain their property and will not normally be destroyed or otherwise disposed of without their agreement.

In the event that the patient is unable to consent to the disposal or not of these medicines, agreement can be sought from their carer.

If the patient or carer refuses to agree to the disposal of the medicines, they can either be held in a sealed bag in a separate section of the medicines cupboard away from all the stock medicines until discussion with the multi-disciplinary team or if the patient insists be returned home.

However, the patient and, or their carer must be advised that as the treatment regime will be reviewed whilst the patient is on the ward, it is likely that the supplied discharge medication will be different, and that this may pose a real risk that the wrong medication may be taken in the future.

If there are safety concerns in relation to the medication being returned home, then the nurse in charge, in consultation with the consultant psychiatrist, may make a decision to refuse to return the medicines and have them destroyed.

For the safe disposal of any medicines, staff should refer to the guidelines issued by their supplying pharmacy.

All actions taken should be fully documented within the patient’s clinical record.

5.12.5.11 Suspected illegal drugs

The trust does not condone the use of illicit substances and in accordance with its duties under the Misuse of Drugs Act (Home Office 1971) will not knowingly permit the use of, or dealing in, illicit substances on its premises.

If any visitors are seen to be in possession of a suspected illicit substance, they will be asked to leave the premises.

If any visitor is seen to, or suspected to have passed illicit substances to a patient or other visitor, they will be asked to leave.

The nurse in charge of the ward will then consult with the matron or service manager about the need to report the matter to the police and consider the appropriateness of further visits by this person.

In the event that it is a patient who is suspected to have illicit substances upon their person or within their room or belongings, the nurse in charge of the ward will discuss their suspicions with them and ask that they voluntarily hand over the substance for destruction.

This discussion must be held in the company of another staff member who will act as witness to the handing over and disposal of the suspected illegal drug.

The illicit substance will be:

1. placed in an envelope
2. an entry will be made in the controlled drug register under the heading of unidentified substance
3. the envelope will be labelled with a reference number linking it to the entry in the controlled drugs register
4. the envelope will be sealed. Both the nurse in charge and the witnessing staff member will sign and date across the sealed flap of the envelope
5. the envelope will then be locked in the ward’s controlled drug cupboard
6. in order to maintain patient confidentiality, their name will not be documented in the controlled drug register
7. the chief pharmacist, accountable officer for controlled drugs, should be notified of the unknown or illicit substance as soon as it is practicable and arrangements will be made for the removal and safe disposal of the substance by the trust pharmacy department
8. if staff involved in the removal of illicit substances from a patient have reason to suspect that the quantity involved is greater than for personal use, advice should be sought from the modern matron with regard to the need for the matter to be reported to the police

Note, under no circumstances will any suspected illicit substances be returned to the patient. If the patient refuses to hand over the illicit substance for destruction, they are to be placed on one-to-one nursing observations and the need for further action, including searching, will be discussed with the modern matron and the patient’s consultant psychiatrist.

All actions taken will be recorded in the patient’s clinical record, or in the case of a visitor, on the ward report.

An electronic incident form (IR1) will be completed and submitted for all incidents.

5.12.5.12 Weapons

Small sharps can be disposed of in the ward sharps bins, but with regard to any guns, hunting knives or other items that staff are unsure about, the police should be notified, and will collect and dispose of the item. An entry will be made in the patient’s clinical record indicating what was disposed of, when, and by whom.

Note, under no circumstances will illicit or dangerous items be stored and returned. Nor will anyone be compensated for the loss of such items.

5.13 Security

5.13.1 Aim

The aim of this document is to outline appropriate procedures for all colleagues working in the forensic service, based upon the “See, Think, Act” principles, offering set standards which meet the additional guidance of Forensic Quality Network Standards for Forensic Mental Health Services: Low and Medium Secure Care, Fourth Edition 2021, and the patients with a mental health problem and learning disability management policy, NHSE Health Building Note for Medium and Low Secure Mental Health Facilities for Adults 2024.

To develop a culture that recognises the importance of security and to support the delivery of a safe therapeutic environment.

5.13.2 Scope

This procedural document applies specifically to the forensic service and provides procedural guidance for use by inpatient services in this specific setting.

5.13.3 Responsibilities, accountabilities and duties

5.13.3.1 Shift co-ordinator

The shift co-ordinator is responsible for nominating a security officer from colleagues on the shift rota and informing them of their role. The shift co-ordinator will confirm that the security officer understands the duties of the role.

All documentation is to be verified by the shift co-ordinator on duty.

5.13.3.2 Security officer

The overall responsibility of the security officer is to check that all necessary security procedures have taken place and all the necessary paperwork is filled out correctly. The security officer must advise the shift co-ordinator immediately regarding any breaches in security.

The security team members will attend the appropriate meetings and take the lead on security forums and audits.

5.13.3.3 All colleagues

All colleagues must adhere to the guidance in this document and are responsible for ensuring standards are met and implemented. Failure by any colleagues to follow this security guidance can lead to disciplinary process, due to the implications that may arise if any relational, physical or procedural security measures are breached. All colleagues must attend the mandatory enhanced security training on an annual basis.

5.13.4 Procedure

Within the service there are specific security procedures which must be adhered to daily. All colleagues are responsible for the security and safety of all patients, visitors and the environment.

At the beginning of a shift one colleague will be identified by the shift co-ordinator to undertake the role of nominated security officer. Both staff nurses and support workers can fulfil this role.

At commencement and end of the shift, the shift co-ordinator will complete a visual check of all patients and sign the security sheet to indicate all patients are accounted for. This task cannot be delegated to any other colleague.

The shift co-ordinator is responsible for ensuring that the safe check is completed and recorded on the security documentation and retains the responsibility for this if delegated to an identified colleague.

The security officer must complete all routine security checks as follows:

• room alarm schedule
• environmental checklist
• cutlery security items
• razor checklist
• Amber Lodge keys, bleeps and personal alarm check
• colleagues signing in or out sheet
• Amber Lodge razor and nail clipper checklist, daily and weekly and signing in or out
• Amber Lodge grey cabinet checklist
• safe checklists

The security officer will be required to sign the security check sheet on completion of all security checks. The security officer is accountable to the shift co-ordinator for these duties.

The security officer is not to be given escorting duties and is to remain on the ward, other than during their break.

5.13.4.1 Amber Lodge low secure, perimeter fence check

The security officer and shift co-ordinator must adhere to the following:

• the security officers from both shifts (current and oncoming) must together carry out a check of the external perimeter fence and surrounding area during the security handover at midday
• the perimeter check is to be carried out once daily during the afternoon handover
• report to the shift co-ordinator any concerns regarding the integrity of the perimeter fence, the surrounding area or the windows and doors
• the shift co-ordinator will clearly document areas of concern and share the relevant information with the colleagues to maintain safety on the ward. Any safety or security issues will be escalated to the sister or senior sister or ward manager or matron or service manager or on-call manager in person or over the phone

5.13.4.2 Security personal alarms or keys or pagers or alarm cancellers

• Keys will be checked 3 times daily by the security officer.
• Pagers or alarms or alarm cancellers will be checked 3 times daily by the security officer.
• Any missing security personal alarms or keys or pagers or alarm cancellers must be reported to the shift co-ordinator immediately.
• The shift co-ordinator will contact the last person to have signed out the missing item to see if they have taken it away with them.
• Following this, if the item is not located, a search of the ward must be carried out.
• If unable to locate the item, the shift co-ordinator is to report any missing personal alarms or keys or pagers or alarm cancellers to the sister or senior sister or ward manager.
• If the missing item which cannot be located is a set of keys, this must be reported on the incident reporting system.

5.13.4.3 Daily security alarm checks and sensors

Colleagues must check the battery on their personal alarm when commencing shift and sign on the signing in or out sheet to confirm that the battery is working.

Any problems with alarms must be reported to estates as a matter of urgency.

Each day the security officer will conduct a sensor test of an alarm to confirm the system is functional and identify any faulty sensors, alarms of pagers. The security team are to pre-plan this testing in the ward diary for the unit and sensors in all rooms must be tested regularly.

Any test undertaken must be recorded in the daily alarm check documentation.

5.13.4.4 Colleagues signing in and out

Personal alarms are available to all colleagues and visitors and are situated in the amber lodge airlock in a key coded cupboard.

Pagers, alerting colleagues to respond to incidents in specific areas, are kept in the key coded room opposite the admin office door at amber lodge.

Colleagues should ensure that they follow the current procedure when accessing keys from the key tracker system, see the accessing keys from the key tracker system forensic service procedure.

Colleagues authorised by the senior sister or ward manager to have access to a set of keys will remove them from the electronic key tracker system at either amber lodge. The key tracker system is located in the key coded room opposite the admin office door at amber lodge.

Colleagues must collect or hand in keys, pagers, personal alarms and alarm cancellers each time they enter or leave the building.

Keys are to be attached to a lanyard, stored in a belt pouch at all times, and retained upon the person whilst on the units. Random checks will be carried out on colleagues by the security team, to audit compliance.

Colleague signing in and out sheets are kept alongside the key tracker system at amber lodge.

5.13.4.5 Visitors, contractors and maintenance workers signing in and out sheet

All visitors, contractors or estates colleagues should:

• be given access via the airlock to each building
• be requested to sign the visitor’s sheet held in the airlock at Amber Lodge upon entering and exiting the building
• be asked to read the prohibited and restricted items lists and to sign to confirm they do not have any listed items upon their person
• be requested to lock personal belongings in the lockers provided in the airlock
• be issued with a personal security alarm
• report to the shift co-ordinator; all contractors and maintenance workers should be supervised by nursing colleagues

Arrangements for safe use of tools must be agreed with the shift co-ordinator and logged whilst in the airlock, prior to access being given to the unit.

Any items brought onto the unit for patients will be checked by the shift co-ordinator in the airlock, and with the visitors present, prior to the visit taking place.

5.13.4.6 Restricted items

Any restricted items will not be allowed to be given to the patient during the visit; visitors will be given a rationale as to why this is not possible. Any problems that colleagues encounter in carrying out this requirement must be reported to the sister or senior sister or ward manager who will advise on further action.

Should any colleagues have any concerns regarding any items being brought onto the unit they must, in the first instance, report this to the shift coordinator or sister or senior sister or ward manager for further support or guidance.

5.13.4.6.1 Razor and nail clipper checklist

• The patient’s individual risk assessment, multi-disciplinary team discussion and care plan will advise colleagues on the level of supervision the patient requires whilst they are shaving and or using nail clippers. This is to be discussed and agreed with the patient’s named nurse and the patient and recorded within the care plan.
• Colleagues will be responsible for monitoring the use of patient’s razors or nail clippers and for signing them out and in on the check sheet inside the security cupboard.
• The security officer will check at handover to make sure that all razors and nail clippers are accounted for and will sign the security booklet.

Colleagues will record on the monitoring sheet when disposable razors are placed in the sharps container.

6 Training implications

6.1 Security procedure, all forensic service colleagues

• How often should this be undertaken: annually.
• Length of training: 2-hour induction, training 3 hours enhanced training (annually once competent in induction training).
• Delivery method: PowerPoint presentation, group work, scenario wall, reflective practice.
• Training delivered by whom: forensic ward manager.
• Where are the records of attendance held: electronic staff record system (ESR).

6.2 Positive behaviour support, all forensic service colleagues

• How often should this be undertaken: when commencing employment with the forensic service.
• Length of training: 2-hour training workbook to be completed.
• Delivery method: PowerPoint presentation, group work, workbook.
• Training delivered by whom: forensic ward manager.
• Where are the records of attendance held: electronic staff record system (ESR).

6.3 Positive behaviour support (prevention and management of violence and aggression)

• How often should this be undertaken: annually.
• Length of training: 2 days.
• Delivery method: face to face.
• Training delivered by whom: learning and development centre.
• Where are the records of attendance held: electronic staff record system (ESR).

7 Monitoring arrangements

7.1 Non adherence to the manual and working procedures

• How: audit and training records.
• Who by: modern matron.
• Reported to: head of specialist services.
• Frequency: various, daily, weekly, monthly, quarterly.

8 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

8.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, “not just clinically but in terms of dignity and respect”.

As a consequence the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

8.1.1 How this will be met

There are no additional requirements in relation to privacy, dignity and respect.

8.2 Mental Capacity Act (2005)

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals’ capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

8.2.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act (2005).

Individual assessment based on personalised care will highlight requirements for capacity assessment. If required these will be undertaken in compliance with the Mental Capacity Act (2005) and appropriate documentation completed for each individualised decision and patient.

9 Links to any other associated documents

This manual policy should be read and implemented in association with the security policy.

10 References

• Department of Health (2002) National Minimum Standards for General Adult Services in Psychiatric Intensive Care Units (PICU) and Low Secure Environments.
• Royal College of Psychiatrists (2023). See Think Act Second Edition.
• Forensic Quality Network (June 2012) for Forensic Mental Health Services Standards for forensic mental health services, Fifth Edition.

11 Appendices

11.1 Appendix A admission to inpatient learning disability forensic services procedure

Refer to appendix A: admission to inpatient learning disability forensic services procedure (staff access only).

11.2 Appendix B approved access to fingerprint access system form A

Refer to appendix B: approved access to fingerprint access system form A (staff access only).

11.3 Appendix C removal from fingerprint access system form B

Refer to appendix C: removal from fingerprint access system form B (staff access only).

11.4 Appendix D audit approved access to fingerprint access system form C

Refer to appendix D: audit approved access to fingerprint access system form C (staff access only).

11.5 Appendix E escort status risk assessment

Refer to appendix E: escort status risk assessment (staff access only).

11.6 Appendix F home risk assessment

Refer to appendix F: home risk assessment (staff access only).

11.7 Appendix G restricted items

Refer to appendix G: restricted items (staff access only).

11.8 Appendix H prohibited items

Refer to appendix H: prohibited items (staff access only).

11.9 Appendix I pro-active search record

Refer to appendix I: pro-active search record (staff access only).

11.10 Appendix J rub-down search

Permission? Pockets empty? Anything unauthorised?

Head, headgear, collar, shoulders (jewellery).

Arm, including watches or cuffs, other arm as above.

Front, sides, waistband, belt (protect privacy and dignity).

Back, waistband, belt.

One leg at a time, buttock, pocket, inside leg, outside leg, hem. Check floor area.

11.11 Appendix K receipt booklet order details

The receipt booklet can be ordered via NHS supply chain
order details as follows:

• duplicate book 125mm by 200mm
• product order code, WEL208
• cost per item, 83p

11.12 Appendix L search box inventory

Refer to appendix L: search box inventory (staff access only).

11.13 Appendix M patient debrief template

Refer to appendix M: patient debrief template (staff access only).

11.14 Appendix N staff debrief template

Refer to appendix N: staff debrief template (staff access only).

11.15 Appendix O unauthorised absence of a person detained under the Mental Health Act (1983)

Refer to appendix O: unauthorised absence of a person detained under the Mental Health Act (1983) (staff access only).

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Document control

• Version: 3.1.
• Approved by: clinical policies review and approval group.
• Date approved: 5 March 2024.
• Name of originator or author: forensic ward manager.
• Name of responsible committee or individual: director of psychological professionals and therapies.
• Unique reference number: 523.
• Date issued: 12 August 2025.
• Review date: 30 April 2027.

Page last reviewed: November 18, 2025
Next review due: November 18, 2026

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